Putting Principles before Personalities

[Davey Do]

Last night, while reconcilating MARs, I noted that an 8 y/o Patient had been prescribed Depakote 250 mg am/500mg pm. The PharmD had transcribed it as 250mg and 500mg am. The med had been administered for two days as a single dose. The MN Nurse who had reconciled the previous two nights MARs had allowed the order to stand as transcribed.

I contacted Pharmacy in order to gain a consensual perspective, thinking that I could have missed something, which I do sometimes. No, I hadn't and the MAR was corrected. I contacted the MD, informed him of the original order, the actual administration, and the rectification. He said, "That's fine." I let the House Suprvisor know what was going on and she reinforced that I should also fill out a Med Variance form.

Tonight, I'm working with the MN Nurse who allowed the order to stand as transcribed. I informed her in private of the variance at the beginning of the shift. She said, "I don't do that, but you gotta do what you gotta do."

I sensed she was upset with the occurence. After things had settled down, I approached her with my my observation. Basically, what transpired during the conversation was: She accused me of selectively following protocol, attempted to bring heresay into the conversation, accused me of acting due to personal reasons, and interrupted twice while I was speaking. I told her that no good was coming from this conversation and ended it.

I'm O.K. with my actions in this situation. Had I acted totally out of emotions, I might have been able to just shine this situation on. However, I am a Nurse first and believe I acted according to my beliefs and principles.

Too bad we can't be Peers and friendly acquaitances.

Oh well. What are you gonna do, but live and let live?

Thanks for allowing me to process this emotionally-charged situation.

Dave

[Davey Do]

I thank you all for your support and your perspectives.

The problem-solving process was a systematically logical action. The emotional variable came into play when I made a decision to attempt to process the situation with my Peer. I wanted to treat the other Nurse as I would have wanted to be treated had the tables been turned. And those are the words that I used to begin the conversation. I wanted to let the other Nurse know that no personal motives were involved.

When the other Nurse became defensive, I knew that the intent of my actions were not being recieved. So, I ended the communication before it esculated into something which neither of us could control.

The night progressed without incident and we treated each other civilly.

Some situations involving errors can be easily overlooked and need not be dealt with an intervention such as this. One such example would have been if the Patient had not recieved the medication. That would have merely entailed the correction of the transcription and notifcation of involved parties. When the Patient had recieved the dose that was not as the MD had prescribed, the invasive reporting process needed to take place.

Primarily, I deal with the Adult Psychiatric population. That is my comfort zone. However, when I am assigned to the Children's Psychiatric Unit, I tend to be hypervigil.

I was aware that Depakote can cause hepatic dysfunction such as agranulocytosis in adults. This is one reason liver function tests and valproic acid levels are monitored during this type of treatment. In researching the untoward effects of Depakote, I also found that hemorrhagic pancreatitis can result with a rapid progression from the initial symptoms to death.

All the literature I studied noted for the treatment of manic episodes associated with Bipolar D/O, the Depakote doses are divided into two or more smaller doses per day. This information reinforced my action to contact the MD and follow through accordingly.

So, as I said in my initial post, I am comfortable with my handling of the situation.

Once again, I want to thank each and every one of you for your input.

Dave