Questioning Doctor's Order

Editorial Team / Admin · Nov 1, 2008

Good question.

You may never have to face anything like this.

And, then again, you may.

As a nurse and patient advocate, you have an obligation to protect your patient. For example, always question an order that:

Is outright illegal/fraudulent
Is not within your Scope of Practice or within your license to carry out
Is against your entity's policy/procedure/protocol
Has a potential to result in undue harm to the patient

Follow these helpful guidelines if you question an order that could fall under the above guidelines:

The nurse should first discuss the order with the healthcare provider who gave the order
If the first step does not resolve the issue, report to immediate supervisor
Document the situation according to your facility's policy/procedure/protocol
Complete an incident/variance report
The nurse may (per state mandate) be required to report the healthcare provider to the appropriate authorities if his/her actions compromised the well-being (endangers the life) of the patient

loricatus · Nov 1, 2008

I do it this way:

MD notified of holding scheduled lopressor administration d/t HR of 50, BP 88/38 & no parameters given for holding med, no new orders rec'd, charge nurse notified.

FireStarterRN, BSN, RN · Nov 1, 2008

Thanks for bringing up this important issue, Pagan!

pagandeva2000, LPN · Nov 1, 2008

Thank you for the clarity sirI and for an example, loricatus. Say I contacted the pharmacy and they also further enlightened me, would I document this as well? I am thinking that as the nurse that is doubting an order, that evidence of the credible resource person (i.e. the pharmacist) should also be documented. Am I making sense in that area as well, or should it be left out?

Thank you!

FireStarterRN, BSN, RN · Nov 1, 2008

I have documented my calls to pharmacy, including the name of the pharmacist. Such as: "Informed Ken in pharmacy pt BUN and Creatinine, he is aware, he states to go ahead and give this dose of Gentamycin, he will adjust dose for tommorrow".

pagandeva2000, LPN · Nov 1, 2008

This can be an issue if a nurse is not diligent enough. I noticed many nurses cave in and just administer simply because they don't know how to handle the situation or document their reasonings of why it wasn't done. I'm not that type, though, but have seen many that have succumbed due to pressure.

pagandeva2000, LPN · Nov 1, 2008

Now that I think of it, I almost got into a situation when I worked per diem in med-surg a few weeks ago, but the route of administration of the medication saved me;

A patient had an order for Azactam (an antibiotic) IV. Never heard of the medication before, so, I looked it up and one of the things I read was something along the lines of proceed with caution with patients who have allergies to penicillin. Lucky me, I see on the MAR that the patient has allergies to penicillin. Looked up the information from two resources provided by the hospital-the micromedix as well as the pill guide on the electronic MAR. Took it to the RN and she told me that the patient had been taking it for a few days already. I still wasn't comfortable, so, I went to the patient, asked her what sort of reaction did she experience with penicillin (I was weighing in my mind what to say to the pharmacy-the next call I was going to make), and decided to take a look at the medlock and at least flush it since I had other IV meds to give. Find that there is no peripheral site IV line. Since it is out of the scope of practice for LPNs to deal with Central and PICC lines in my state, I never saw one before, didn't think to look, and went back to the RN and asked her where was the line. She shows me the Central line, and (never mind the fact that I am not allowed to touch these lines because I had forgotten that) but I told the nurse that I never saw this before, was never oriented how to use this line, so, I am not going to do it. This RN tells me that "LPNs do it all the time" and I said "Not THIS LPN! I never saw this route of administration in class, nor was oriented to this, so, until I verify with the BON, I don't feel safe administering this medication this route. I'll give the PO medications, the dressings (but not the central line dressings), and the rest is on you". Therefore, I was let off the hook on having to even deal with the Azactam medication issue. When I got home, emailed the BON and they send me the state policy, which basically said that the only thing an LPN in New York can do regarding a Central/PICC line is to gather the equipment. Now, the LPNs that are taking the risk to hang those meds the route that they are not legally able to do...well, that's their problem, sorry to say...

But this, would have probably had been an issue where I would have read that the patient had been on Azactam for 3 days with no incident, and on further reading from other resources, would have discovered that most times, this medication is, in fact, prescribed for those with allergic reactions to penicillin. If I were faced with this, seeing that the patient handled it thus far, I might have given it. Another question I have is: Say I decided that since the patient had been on it for days with no reaction, read resources, called the pharmacy, etc, and decided to administer, how would I document the fact that I did do my research and the medication was administered?

shellsgogreen · Nov 1, 2008

i've had patients with known allergies to penicillin, and they've ordered them, however the md writes "known allergy " as part of the order.

as far as administering, i was of course very cautious and questioned everything from the need for it to specifically what the patient has felt previously.

when i documented, i noted that it was a known allergy, approved by the md, s/e explained to patient and so forth . then after it was given i documented what the response was (then breathed a sigh of relief :uhoh21:)

mama_d, BSN, RN · Nov 1, 2008

but this, would have probably had been an issue where i would have read that the patient had been on azactam for 3 days with no incident, and on further reading from other resources, would have discovered that most times, this medication is, in fact, prescribed for those with allergic reactions to penicillin. if i were faced with this, seeing that the patient handled it thus far, i might have given it. another question i have is: say i decided that since the patient had been on it for days with no reaction, read resources, called the pharmacy, etc, and decided to administer, how would i document the fact that i did do my research and the medication was administered?

i would have charted just that..."noted that pt has allergy to pcn, references (micromedex) note possible cross-allergy with azactam, spoke with jane in pharmacy re: azactam ordered with pcn allergy. jane states x% possiblity of reaction. pt has rec'd azactam iv x3 days without possible allergic reactions noted. pt states pcn allergy manifested as hives/itching. called dr. smith to discuss situation, including possible need for prn medication in event of allergic reaction, no new orders rec'd. azactam iv initiated at 2100, will closely monitor for adverse reactions."

with a follow up note when iv done:

"azactam iv completed at 2130, no s/s of adverse reaction noted. will con't to monitor and note s/s of adverse reaction if any arise."

i am notorious on my floor for charting out the wazoo whenever situation like this arise, but i figure the more thorough i am, the more protected i am.

pagandeva2000, LPN · Nov 1, 2008

but this, would have probably had been an issue where i would have read that the patient had been on azactam for 3 days with no incident, and on further reading from other resources, would have discovered that most times, this medication is, in fact, prescribed for those with allergic reactions to penicillin. if i were faced with this, seeing that the patient handled it thus far, i might have given it. another question i have is: say i decided that since the patient had been on it for days with no reaction, read resources, called the pharmacy, etc, and decided to administer, how would i document the fact that i did do my research and the medication was administered?
i would have charted just that..."noted that pt has allergy to pcn, references (micromedex) note possible cross-allergy with azactam, spoke with jane in pharmacy re: azactam ordered with pcn allergy. jane states x% possiblity of reaction. pt has rec'd azactam iv x3 days without possible allergic reactions noted. pt states pcn allergy manifested as hives/itching. called dr. smith to discuss situation, including possible need for prn medication in event of allergic reaction, no new orders rec'd. azactam iv initiated at 2100, will closely monitor for adverse reactions."
with a follow up note when iv done:
"azactam iv completed at 2130, no s/s of adverse reaction noted. will con't to monitor and note s/s of adverse reaction if any arise."
i am notorious on my floor for charting out the wazoo whenever situation like this arise, but i figure the more thorough i am, the more protected i am.

greatly appreciated! i love this forum, allnurses! we can collect so many ideas from each other regarding issues before they happen. if i ever come across this again, i will remember this post like a mantra! :up: :yeah: :bow: :bowingpur

mama_d, BSN, RN · Nov 1, 2008

Can you tell I've been down this road before?

Glad to be of help!