I Need Advice - MD Not Signing Order

[Andrew, RN]

Hey everyone. I'm a RN working in a PACU. At my facility, CRNAs do the cases and there is one float MD that is there as a resource. We have "protocols" to give meds for pain/nausea without needing to call the doctor. The doctor then signs the order some time later, often not seeing the patient ever.

Here's my problem. I had a patient that just had a very painful ankle surgery. The surgeon wrote for a dilaudid PCA. I called the pain nurse to come and set it up. In the mean time, the patient was hurting at a "12 out of 10" and their vital signs/facial expressions reflected this. The pain nurse told me it would take her a while to get there and that I could give the patient some dilaudid IVP. Nothing wrong with that, we do it all the time. Basically, we are giving the patient their loading dose that the pain service nurse would be giving anyway once they get the PCA set up.

So, I give her 1mg IVP. Waited 5 minutes, gave another 1mg. The patient's pain went down and I left it at that. I wrote my order for it. The patient had a good outcome and had pain relief. This was earlier in the week.

Fastforward to today. I get called into my charge RN's office. The anesthesiologist is refusing to sign this order. I got sent home and they are going to talk to the pain service nurse later today when she comes in at 3 pm. I'm not sure if I'm going to have a job and it's up to "how far" the doctor wants to take this.

Basically, I was going by our protocols and giving the patient a medication in a manner consistent with its guidelines. I don't know what to do.

I wrote the order as "Hydromorphone 0.5-1mg IVP q 5-7 minutes MAX of 4mg" and I only gave 2mg.

This sucks. =(

[BittyBabyGrower, MSN, RN]

I'm sorry this happened to you. When writing a verbal/telephone order, make sure you document who you spoke to and read back what they said to you. Also, does your hospital have issues with sliding orders such as 1mg-5mg q10-20 minutes? This can be construed, sometimes, as medical management. We can no longer have such orders where I work, it has to be a specific dose, unless it is written in a preprinted titration protocol, such as most ICU settings have. He may be having an issue with the fact that you did not start at the lower dose and interval, instead you jumped to the higher dose and interval. JMHO.

[RN1982]

Playing Satan's advocate but if you didn't have written orders from the doc, but medicated the patient anyways, that can be construed as "practicing outside your scope". Also, I would like you to clarify with us, the role of the pain nurse. Is she an advanced practive RN? Does she have the authority to prescribe narcotics without a physcian's go-ahead? In the future, I suggest not medicating a patient without a signed order from the physician no matter often the practice is to medicate the patient, get a signed order later. It's your license, protect it.

[sjt9721, BSN, RN]

I'm sorry this happened to you. Sounds like you are being a scapegoat here. I would start looking for a new job today. Pls don't let this scare you away from nursing. You will find your fit and sometimes that takes time.

Scapegoat, maybe. It does suck when a tolerated practice suddenly catches someone unawares.

The real scary thing is that this type of incident could be reportable to the BON. And the Board won't care about the reasons why.

I don't want him to be scared away from nursing either...but it's very important that he learn from this experience.

[Vito Andolini]

My manager is telling me the reason he won't sign it is because I "didn't talk to him first about it".

Which makes no sense. We give fentanyl, we give morphine, we give antiemetics without talking to him. Why would dilaudid be any different? There were no problems that he needed to be contacted with.

Ask him and your boss why it's different this time. What I see that you did wrong was to take an order from a nurse. Was this an AP nurse who can legally give orders? If so, she should sign it and be done with it. But if she isn't and if you indicated that the doctor gave you the order, I can see why the doc would be upset. Although it sounds like this type of behavior is not uncommon (you guys working from protocols, that is, docs signing later).

From now on, require a signature before you act. In fact, make them write their own orders, don't take TO or VO's. Of course, you'll be in trouble for that refusal, too. I guess you could have cleared it with the charge nurse and gotten her to co-sign so you'd at least have a witness to the fact that you didn't just prescribe it yourself.

[RN1982]

I agree with Vito. Do not medicate a patient without an order signed by the physican. Saves you a lot of hassle. Saves your butt. Saves your license. This is a very important lesson that you have learned. Just because something is common practice doesn't mean it's right or legal for that matter.

[Vito Andolini]

Pain nurse is saying that she gave me an order to medicate the patient, not necessarily a dilaudid order.

They took away my weekend call and told me to stay home on Monday. They're going to meet with me on Tuesday. I want to sit down and talk with this doctor so we can figure out what the problem is and what we can do about it.

Fie on the pain nurse, dude. She's being a real butthead, seems to me, based on what you say she said and which she is now denying. And if she didn't say Dilaudid, what does she say she said? Sad lesson - when trouble comes, everybody covers himself.

Definitely do talk to the doctor and see what his exact beef is.

If you do get fired/reported to BON/whatever, hold your head high. Talk with a couple of lawyers, ask for retraining, ask for a 2nd chance, own up to the error and take your lumps. they'll respect you more if you can admit you screwed up but really really would be grateful for a 2nd chance.

Dude, we all make errors, we are all fallible. Do NOT leave the field of Nursing if you genuinely want to be a nurse. Most days go better than this. Hang in there, please. We need you.

[Vito Andolini]

This is what I'm hoping for.

This department needs better order sheets and more things in writing than what they have now. There are no protocols in writing, it is just an understood thing that you can give certain drugs in certain situations. I've never felt comfortable with it. The other nurses I work with have been there for 20+ years so they're used to doing things "the way they've always been done" even though they aren't exactly the most legal way. I always have to ask people "What do you normally do in this situation?"

I think JCAHO would find it appalling that so-called protocols aren't in writing. I think heads higher up than yours should roll over that.

But do you see? Lots of times I think people don't put stuff in writing so that they can be non-accountable. They can say whatever they want and there is no one to tell them they're wrong.

Talk with a lawyer. you might want to work where they have written protocols. Legal or illegal - no in between.

Do the DON and Risk Manager know that stuff is done by the seat of the pants, no written protocols, nurses just doing what they've always done, supposedly?

[Vito Andolini]

When dealing with an overboard doctor or other staff member, it is best to CYA all the way. If things go ok for you, in the future, never do anything with this doctor that is not to the T the way it should be. Assume nothing with him, always put it in writing and get his signature or a TO from him before proceeding.

No more TO's from him. Make him write exactly what he wants. Take him the chart if you have to but make him write the orders.

Also, while everything is fresh in your mind, write the whole thing down. Who, what, when, how, where, why, everything.

[RN1982]

I would look into finding another job also. This place seems unsafe...for you.

[TuTonka]

Hang in there if your pain nurse backs you up things should be ok. The wonderful suggestion from the other nurses are good ones. Remember you learn something new in nursing every day no matter how small or how big 5 yrs from now WOW what an outstanding nurse will evolve. Do not give up! The pt pain decreased....Good nursing care my friend!!!!!!!!!!!!

[massrn116]

I would say in the future make the MD come to the patient and write it himself to protect you.

[Andrew, RN]

Some of this advice is helpful, some of it isn't. Thanks anyway for those who have commented.

Here's some facts. The hospital is not JCAHO so their standards don't apply here.

The pain nurse is a RN, not AP. They write orders all the time that later get signed by the anesthesiologist, just like I do, only they write much more... PO opioids, sleep aids, toradol, etc etc.

In the given situation, I have done nothing wrong. The patient had pain, I treated it using a drug that they were prescribed to get. It's a gray area I am in. Perhaps if I had given fentanyl (a drug the anesthesiologist seems to be more comfortable with) instead I would not be in this mess and the doctor would have signed the order, but I gave dilaudid because that is the drug the patient was to receive via PCA.

The pain nurses often times when setting up the PCAs will give a loading dose starting with 2mg and redose 1-2mg at a time. I've seen them give 4-6 before. Every patient is different and requires a different dose for dilaudid. To the person that says "OMG it's 8 times more potent than morphine blah blah blah"... It's 2-8 times more potent, depending on the patient.

I gave 1mg, repeated it, then stopped. There was no harm done to the patient. Nothing bad happened. They're just singling me out. I gave a normal loading dose that the pain service nurse would have given. She was sitting around in the breakroom instead of being at the bedside treating the patient's pain. So I did.

This is what I hate about nursing. Infinite responsibility and no real power to do anything.