MD orders for meds

[PMHNP10]

I saw the thread about carrying out MD orders and I was reminded of a situation which occurred a couple weeks ago. A morbidly obese pt had ordered synthroid 100 mcg PO. A couple days later the MD wrote an order "synthroid 250 mcg IV QD" A few days later some of the nurses (myself not included) were written up with warnings. According to the MD he wanted us to give both dosages of synthroid. The pharmacy when transcribing the orders removed the PO dose of synthroid, and the night nurses did not rewrite the PO dose on the MAR. First off, the 250 mcg IV is a pretty extensive dose of synthroid (unless treating for myxedema coma), but that isn't my decision to make, it's the MD's. My problem with the whole thing is that it has always been my understanding that when the MD writes a 2nd order for a medication (with a change in dose or route) the new order supercedes the old order. I am well aware that when in doubt verify with the doctor. However, there comes a time there is no doubt and as a result there is not a second thought to clarify with the MD.

The night nurses who didn't correct the MAR signed the warning because they were too tired to fight over it, but the day nurse who failed to give the PO dose refused to sign. Needless to say, no pharmacist saw a writeup. Of course, had the physician simply stated to continue the PO dose, there would have been no missed med, only nurses questioning the order for so much.

Is this an instance where the nurses are in the wrong for not questioning? Also, where is that line drawn when you take what the MD writes at face value vs questioning everything and anything the MD writes?

[lucianne]

The first order must be d/c'd in writing or by verbal order. Of course, it would have been wisest to write "continue 100mcg po" with the second order but that didn't happen. I have had doctors write orders for new dosages and sometimes they are additional and sometimes they replace the old orders. If it isn't clear, I always ask and someone in your facility should have done the same. You can't assume you know what the docs want. You said the pharmacy removed the po orders, though. I wouldn't have continued the po dose if it wasn't in the MAR. Who has time to check the charts for all med orders? On our unit, a nurse must submit all written med orders to pharmacy (or double check the unit secretary) and we have to trust that they've been entered correctly. If the pharmacy takes it upon themselves to d/c orders, then what can you do?

luci

[Agnus]

Another system error. This might be the imputis to develop protochols. I would bring the MD, the pharmasist and nuring to the table to draw up protochols for such a situation. The protochols ideally will include a system of checks, to insure an order is clear.

[PMHNP10]

Originally posted by lucianne

The first order must be d/c'd in writing or by verbal order. I have had doctors write orders for new dosages and sometimes they are additional and sometimes they replace the old orders. If it isn't clear, I always ask and someone in your facility should have done the same. You can't assume you know what the docs want. You said the pharmacy removed the po orders, though. I wouldn't have continued the po dose if it wasn't in the MAR. Who has time to check the charts for all med orders? On our unit, a nurse must submit all written med orders to pharmacy (or double check the unit secretary) and we have to trust that they've been entered correctly. If the pharmacy takes it upon themselves to d/c orders, then what can you do?

luci

On our unit, the nurse transcribes the orders and is checked off by another nurse. We also have a medication profile where each med is written out, and when a med is dc'd, it is yellowed out, so you don't have to check through the entire chart. So I assume the night nurse agreed with the pharmacy and left the PO dose off the MAR. I agree, if you have a question, verify with the MD. There was no question here though. It seemed cut and dry because an order was written for the same med in a different dose and route at the same time. That is where my question comes in. I know that we as nurses don't question these kind of orders all the time because logic tells you the new eliminates the old. For example, who is going to question when a MD writes an order for "lortab 10/500 PO TID" when the original medication is "vicodin 5/500 PO TID". I may be wrong, but I'd be willing to bet any prudent nurse is going to stop giving the vicodin and just give the new dose of lortab. There is no question here. So how is the synthroid different?

[canoehead, BSN, RN]

I would have assumed the po was to be discontinued but I would have questioned him on increasing the dose by 250% all at once.

[stressednurse]

Does anyone talk to the doc about what he is writing orders for? Or does a charge nurse and/or the nurse taking care of the patient talk to the doc who writes the order?

Making rounds so to speak with docs does help with the human error thing. Docs...believe it or not are human too.

Oh, geeze,.... I forgot, I work in the US and am a nurse who is unreasonably made responsible for everyone elses errors.

Nursing shortage.... Nope, just too many of us are too smart to play that game anymore.

Charge Nurse...No one has enough time to make rounds with the doc, we have more pressing matters. Go to care planning, go to meetings about management, go to meetings about better care, go to meetings about complaints.

Bedside nurse is too busy emptying the trash to notice the doc is in the room. Had she know that he was going to be there around that time of day she could have looked for him. Charge nurse couldn't find her to tell her cuz she was potting patients before lunch cuz there are less nurse aids to help with that.

Doc would like to let us know when he will visit but he has to take care of 30% more patients cuz of the HMO requirements and he can't pay his gross malpractice insurance bill if he dosen't do that.

Patients still want personal care from doc and nurse and both what to give that. But they have to see more patients and deal with more work cuz of the health care reform.

Then there are the patients that seem to think they checked into the Hilton. And for some unknown reason.....management loves them. They whimper and we are shit.

[PMHNP10]

Originally posted by canoehead

I would have assumed the po was to be discontinued but I would have questioned him on increasing the dose by 250% all at once.

Such an increase is not unheard of, if the smaller dose was not effective in pain management, and you would obviously know as the pt's nurse. But if this really is something you would question, then switch it around: pt is on lortab 10/500 PO TID then later lortab 5/500 PO is ordered. There is certainly no question here--a natural progression to reduce pain meds as the pt's condition is improving.

Unless I'm mistaking, I'm thinking your point was that the nurses should have questioned the increase in synthroid from 100 mcg PO to 250 mcg IV and I'm inclined to agree because like I said in my original post, that much synthroid is usually only administered for pts in a myxedema coma. But in asking why there was such a significant increase, I realistically don't see myself asking anything about continuing the PO dose (nor even mentioning it) because I, like you, naturally assume the PO dose is no more.

My point is that this is a dangerous situation. There is a fine line, although very clouded, when we need to get a clarification. Where is that line? Or are we supposed to question every new order that occurs for a medication in which there is no specific instruction in the new order to continue or discontinue, or change? Or am I asking a question which has no clear cut answer.

[PMHNP10]

Originally posted by stressednurse

Making rounds so to speak with docs does help with the human error thing. Docs...believe it or not are human too.

Exactly, they are human, and in the scenario I presented, the MD made the mistake. So why aren't they held accountable?

Why would 1 nurse write up another nurse for a mistake which clearly didn't originate with the nurse, and to be fair, the nurse is only guilty for not being able to read the MD's mind--assuming you feel there is no other aspect of the order which would require a clarification?

[lucianne]

Yes, I would question every time a new order is written for the same med (or new med treating same symptom) and there is no order to D/C the first one. Our docs typically write: "D/C Old Med per route at dose at times. New med, dose, route, times." or write "New med, dose, route, times to be given with old med dose, route, times." Eventually, (hopefully) the MDs will learn to write orders correctly and clearly. Or take it up with administration or management to create a clear policy for the MDs. No matter how obvious you think it is that the MD meant to D/C a med, you can't do it unless the order is written. In the case of someone who appears to be getting an excessive dose, you can hold the med and call for clarification.

luci

PS. I don't think the nurses should have been written up, either. I think the policy needs to be clarified so it doesn't happen again. Why be punitive when there is obviously a breakdown in communication/policy?

[Rapheal]

The day shift nurse reads the mar. It states sythroid 250mcg IV. Since she does not see a PO synthroid order on the MAR what would lead her to believe that one exsists? Do we need to compare our MARS with the pages and pages of orders on the charts- most with inlegible handwriting? If I was the day shift nurse I would not have signed the disciplinary warning either. As for the nurse who transcribed the order- she made a mistake by not asking the doctor. But if he really wants the nursing staff to follow his orders - he should make them more clear. This would just be better for his patients. And if these doctors really cared about their patients (yes I am going to say this- caution to the wind) they would work on their handwriting. It is a crime that treatments are missed or misinterpreted because they will not take the time to write it clearly. Then they have the nerve to blame nursing.

Here is a little poem inspired by the cat in the hat.

Do not squiggle when you write

It gives the nurses such a fright

Do not write your ABC's

so that they look like EBG's

Practice. practice every day

till your squiggles go away