I Need Advice - MD Not Signing Order - page 3
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... Read More
Apr 17, '09Quote from Batman24Scapegoat, maybe. It does suck when a tolerated practice suddenly catches someone unawares.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.
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.
Apr 17, '09Quote from Andrew, RNMy 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.
Apr 17, '09I 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.
Apr 17, '09Quote from Andrew, RNFie 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.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.
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.
Apr 17, '09Quote from Andrew, RNI 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.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?"
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?
Apr 17, '09Quote from caliotter3No 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.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.
Also, while everything is fresh in your mind, write the whole thing down. Who, what, when, how, where, why, everything.
Apr 17, '09Hang 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!!!!!!!!!!!!
Apr 17, '09I would say in the future make the MD come to the patient and write it himself to protect you.
Apr 17, '09Some 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.
Apr 17, '09Hi Andrew - I really, really feel your frustration. Things like this - the gray areas - are the reason I left the hospital setting. I decided long ago to NEVER trust doctors to sign ANYTHING. And I don't trust co-workers who say things like, "It's fine! We do it all the time!!" I had a surgeon tell me once to "just give some norcuron next time your 3 hour post-op open heart freaks out on the vent. You don't need to call me, you're a "critical care nurse", right?" Uhh, yeah, I don't think so. It might be fine the first time, but what happens when he decides NOT to back me up? I've seen too many excellent nurses get thrown to the wolves over things like this. It's always going to boil down the the technicallity of the situation. Not the fact that the outcome was good. You'd THINK that would be taken into consideration, but it doesn't seem to be a deciding factor for nurses who are taken to court, or accused of doing something "out of their scope."
Don't give up on nursing. You went to all the work to earn a degree, don't throw it away. Find something else. Even if it's boring (like office nursing), it will allow you to relax and feel out your options. Luckily, the nursing field has many options. I left the hospital to do chronic dialysis. Luckily, I work with some really great people - this doesn't seem to be the norm in the dialysis world. I don't know if the dialysis field is where I want to stay forever, but at least my license isn't on the line every day.
Anyway, I really hope things work out for you...hang in there!
Apr 17, '09Protocol or standing orders have to be somewhere in writing/computer. We have standard orders in our PACU and the doctors check what they want and can add things not pre-printed. Basically in this case one RN told another RN what to do. A doctor was never involved in the decision process unless you can find this protocol in writing.
I have also seen orders for PCA and a separate order that reads. Dilaudid 0.5mg IV q10min if PCA unavailable.
Like others have said we can't take doses with ranges on the floors where I work. PACU may be different though.
Apr 17, '09It will pass, Andrew. All you can do is explain your side. I doubt your manager particularly blames you- it's usually more about having to soothe the doctor's ego. Maybe after this they will write a policy so that it can be clear in the future. Even if you get reprimanded or disciplined in some way, the main thing to remember is that the patient was not harmed in any way- so the worst case scenario did NOT happen. Don't quit over it. You know, JCAHO is trying to crack down on verbal orders, not only because of errors, but also because there are instances occasionally where a doctor will refuse to sign, saying "that's not what I said." You can never predict what one of those folks (docs) are going to do unless you know them pretty well. Hang in there.