Questioning a doctors order - page 3
Let me begin by stating, I am a new nurse. Been on my own for 3 months now, so I am still learning. However, I was just curious how many nurses out there have been told by management or supervisors... Read More
Apr 13, '17I work nights. This incident was with mu nursing supervisor, whom we are told is our resource to go to with questions and concerns since we don't have the resources days do. We have one very extremely helpful supervisor, he will help with difficult IV's, any questions we have and he will sit down and talk to us like normal human veings. In regards to the supervisor regarding this situation, I know now not to seek advice from in the future.
Apr 14, '17In nursing school, one of my best clinical instructors said "Any trained monkey can be taught to do most of the skills and activities that a nurse does. We are paid the bigger bucks and licensed to recognized when NOT to give a med or not do something ordered because it could harm a patient."
Always question but be ready to explain why you are questioning. Be careful how you word your question. And I like to use the word "clarification"....as in, "The orders are for 10 units of insulin for this patient but his BG is 86, I want to clarify that you still want me to administer this insulin." As for the isolation issue, assuming the patient qualifies in your mind for a specific isolation, I be obligated to file a quality/safety report concerning this.
Is there any chance the patient was admitted on a "rule out" isolation and it was ruled out? I mean c.diff is ruled out by having formed stool...no lab test required (they won't even test formed stool if you sent it). If you have any further questions, you could approach which ever department is in charge of infection control and ask them to help educate you on why this patient was no longer considered an isolation issue.Last edit by blackribbon on Apr 14, '17
Apr 14, '17Quote from MrsJt-Thank you for your reply. It is really disheartening, especially for a new nurse that is still trying to figure things out. I really try not to take things personally, but it is hard when you feel like someone is talking down to you like you are an idiot. Nursing is tough in general, let alone being a new nurse that has management and a supervisor that you feel doesn't support you.
Going back to your original question I would check The Hospital Policies and Procedures for Infection Control or even leave a message for the Infection Control Nurse. In some hospitals were I have worked once a patient has been diagnosed with MRSA even if it was 10 years ago they are automatically isolated. This can represent a costly waste of resources if the patient does not in fact have an active infection. Most hospitals do routine culture of the NARES on all new admissions to isolate MRSA.
Never feel guilty or less than for asking about something you do not know. I have questioned some physician's orders in my time and it's always been the right call at the time.
Apr 14, '17You should always be able to go to your Nursing Sup without a problem..What could have happened was that IF that patient was a direct admit from home or a facility, and she was symptomatic they could have done the UA/CS at that facility and it may have gotten sent to a non hospital lab, then after she was admitted to the hospital the results from that facility came to the Drs attention at his office and that may have been the reasoning behind the Isolation discontinue. Who knows, If physicians would use more explanations when writing orders it sure would answer a lot of questions..who knows for sure..but if the charge nurse made rounds with him she may have known, the reasoning may have gotten dropped somewhere in report. It maybe somewhere in his physician notes. because I wrote so many variables that could have happened I hope that helped..If I saw the physician I would have simply asked if a UA was done elsewhere, Most of the time not all the time Drs will answer..It also could have been an infection control protocol, I worked as a travel nurse for a few years and saw a lot of protocols regarding isolation started because of one certain bacterial infection or another had occurred in the past so many months with that patient..They will Isolate first to protect staff and other patients, then after waiting for a ,b or c lab reports to come back then change the Isolation status . Check your infection control protocols, the answer might be in there..and most insurances will try to get out of paying for 2 of the same labs within a couple days, so it may be the result from another lab that ended the Isolation. That was a simple question..Good girl for asking instead of just assuming..That means you are using your Nursing brain..always question if the reason is not understood..Once we had a strange new physician , sorry his demeanor was just nothing I expected and he was new to the facility and I had an admission at 5am, he wrote for a patient to get 30 units of regular insulin every am..Now this patient came from another facility, so I saw the old Mars, and some nurses notes where he had bottomed out the previous day from a dose of 70/30..I called this Dr back and he said what he wrote was what he meant.and just do it.It was a few years ago when we had to write out the initial Mars..I waited until shift change and contacted the oncoming physician about it and he put the Brakes on about that order..Many errors were caught by good nurses and he did not last long, maybe a week or so and he was gone..Please do not get me wrong, he was kind and always joking with staff, but something was going on mentally and a lot of patients were saved from harm and possible death by good thinking nurses..Sometimes Drs and Nurses somehow something can go wrong mentally and they lose their knowledge, I have seen it happen but only a few times..I mean Boards are tuff so they had to be knowledgeable at some point and time in order to pass them, and I think that was what happened to this Physician, it was sad to see him let go, he was earnestly trying but it was like the lights are on but nobody was home.And patient safety can never be risked..I am betting it is the infection control protocol Sorry if I bored you with all this...Good luckLast edit by nancy welch on Apr 14, '17 : Reason: spelling and word error
Apr 14, '17Say in a polite voice "I have a question about this? I am concerned because..." If you really feel like you can't safely carry the order out, respectfully say "I'm uncomfortable with doing this, I will contact the charge nurse who may be more comfortable doing this, but I am not" Then document it in the medical record. A doctor can administer meds and perform procedures too. If they really believe it should be done, let them come in and do it.
I had a doctor want me to give ativan and I was uncomfortable with giving it due to the level of sedation of the patient, the possible compromise to the airway, and not wanting to deal with having to reverse it. I had multiple competing priorities and this patient did not need Ativan, other nurses and my charge nurse agreed. She said to hold the med and if the doctor pressed me to let her handle it.Last edit by amzyRN on Apr 14, '17
Apr 14, '17Of course. If an order makes no sense question it. The doctors at my hospital often has 10 times the patient load I do. Of course mistakes happens.
Apr 15, '17Always ask questions!! Always ask why! That is the best advice I ever got. So what if a Doctor yells at you. You are there for your patient not for your doctor. I used to hate asking docs for orders or asking peers for advice. After working in ED, I got over that real quick. You need to protect your license, not the Doc's or the supervising RN.
Apr 15, '17I’m a new RN just fresh out of orientation (yesterday was my 3rd day off orientation). I had a case yesterday that I had not questioned an order a patient who needed to be on an insulin drip would have been put into a very serious situation. Here the patient’s blood sugar was consistently high during my 12-hour shift. The pre-dinner/supper blood sugar was over 400; a stat serum blood glucose was 401. I alerted the treatment team of the numbers including the through-the-day numbers. The original MAR was to give 12 and alert the PCP. In my communication (this was done via secure text), I stated I would give 12; but when I got to the patient’s room (they were in isolation), the order was changed to just give 6. As part of the changes, I could see that an insulin drip was ordered but shortly cancelled. I gave six, and then immediately after exiting the room went on a trip to find the NP who put in the original insulin drip order. Thankfully I could find them (they were working late) to let them know 1) I was not able to give the 12 that I stated I would because it was discontinued just moments before I could give it and adjusted to 6, AND that the insulin drip she ordered was also cancelled.
Here another treatment team member, an MD, cancelled the insulin drip and didn’t consider the patient’s current blood sugar, that the 12 wasn’t given (because they cancelled it), and that six units wasn’t going to cut it as the patient was receiving regular IV steroids in addition to being a diabetic. Thankfully the NP could put in another set of orders for an insulin drip plus a one-time stat order for 12 units.
Had I just “followed orders,” and gave the six units the patient might have suffered preventable harm.
Apr 15, '17In my own personal experience I've found nursing to be no different than any where else in the fact most people won't spare the time to praise for a job well done (unless you've done something extraordinary - like save a whole family from a burning building, or rescued a puppy from a well) however on the other hand typically a person will take the time to point out an error. If I called it human nature 101 this would sound so very condescending and that is not my intent, so let's just call it the way of the world.
Being a new grad nurse is some scary stuff - all of the responsibility but none of the crucial life or career experience to draw from or fall back on yet. That leaves the fledgling nurse very vulnerable and exposed, and in need of someone like me - a seasoned old grizzly bear to give sound advice and look out for those nursing cubs under my wing of protection. And mother bear I do very well to protect my cubs - my familial ones, and the ones of the career variety. ROAR!!!
From my own experience it never hurts to clarify an order, and you don't need your supervisor's approval to do this. Consider it to be a gold standard multi check point safety system designed to make sure everyone is on the same page. And think of yourself as one link in a long chain that creates a safety net for the patient.
Providers are human too which subjects them to sleepless nights, sick children, aging parents, and arguments with partners to name a few - all of which could potentially affect their state of mind on any given day as well as their ability to write a clear order.
In time you'll see some whoppers of an order too - some will make you chuckle, others will make you gasp, and yet some very special ones you will bring to all of us for entertainment on this very chat board.
My point is this: you must CYOA if you are to carry out orders. If you see one that looks off, then it probably is. To execute an order like that could potentially harm a patient and place you in jeopardy. And trust me, the SBON will not absolve you of the part you played if a patient is harmed on your watch due to the excuse of "I knew it looked off, but my charge nurse told me never to question an order". A defense like that would fold like a house of cards. And I'm betting an elf's popcorn fart that your charge nurse will not come along to defend you against the SBON if that scenario ever happened.
Another thing to consider: What would your old nursing instructors say if they heard you buckled to that way of thinking? They'd kick your butt, no? You bet they would!
Nursing school was all about drilling into each nursing student: patient safety, patient safety, patient safety! Grab that important motto - weave it into body armour and wrap it around yourself like a talisman. You are Nurse Safety Queen: the shining knight to all patients in need!
In nursing it is your first and foremost job to question. Without free conscious thought and independent reasoning ability everything else is moot anyway.Last edit by 3ringnursing on Apr 15, '17
Apr 15, '17You didn't bore me, lol. Thank you for your input. Yhe pt was an admit from home d/t a fall. Our nursing supervisors are basically on for staffing purposes, placing admissions, and if a pt is going for a surgical procedure the next day, and to be present during codes. Other than that, they really aren't involved much more with the pt. They do rounds on each floor on nights and afternoons. They do not physically see the pts. They are also supposed to be resources for us on nights if we have questions and concerns. The 1 supervisor is great, but this 1 not so much. We don't officially have a charge nurse at night, so I thought the best thing to do before calling to wake a doc up in the middle of the night, was to seek her advice when she rounded. Apparently, she didnt agree.Last edit by MrsJt on Apr 15, '17
Apr 15, '17To the OP, I'm sorry that this was the response you encountered to a good question about patient care. As nurses, we need to remain vigilant about checking orders for our patients that are entered by LIP (physicians, nurse practitioners and physician assistants) as well as those from other disciplines (pharmacy, PT/OT, dietary, speech therapy etc. to make sure that they are safe and appropriate. Another user mentioned that many of the tasks that we do can easily be taught to anyone (monkey or otherwise) but the difference is the critical thinking that accompanies the carrying out of these tasks.
Now here is some food for thought, you mentioned that it was your nursing supervisor who scolded you for suggesting that you question the physician's order. I have found in my nursing career that how nurses interact with physician's and other LIPs is highly culturally dependent. Keep in mind when I use the word culture I don't just mean race or country of birth/origin. When I use the word "culture" I'm referring to the total picture that includes: age, generation, race, religion, gender, personal communication style, educational background, institutional politics/hierarchy and other factors. I don't wish to make sweeping generalizations but I have noticed that sometimes nurses from certain cultural groups may be less likely to question the orders a physician because that was how they were raised. I have also noticed that nurses who are from the Baby Boomer generation approach communication and organizational hierarchy differently than Generation Y as another example. We should also keep in mind how someone's nursing education and background may play into this as well. I once worked with a nursing supervisor who was very knowledgeable in our speciality but he often told me that his ADN program emphasized the role of the nurse in carrying out orders and delivering care so he often felt that it wasn't in the RNs role to "challenege" the physician, although he would vocalize his concerns in obvious cases of a mistake on the part of the doctor.
My only suggestion to the OP is when you have a question or concern about an order that you use a little finesse when "questioning" the order. I will review an LIPs progress notes at the time of the order change to see if they have discussed why they are writing a specific order and if it isn't addressed then I will contact them to "seek further clarification" or to "help me understand the rationale for my knowledge/education" and usually it goes over without an issue. I try to ask myself, is this something that I really need to address at this time (e.g. when I worked nights on a med/surg unit I tried not to call at 3 AM for an order that could wait to be addressed when the team did rounds in the morning).
Keep your chin up OP and try to remember that it IS your job to question the safety and appropriateness of orders for your patients (just doing so in a mature, professional way).
Apr 15, '17Then 1950s are calling and they want those nurses back. It is our duty as health care professionals to question orders from doctors and nurse practitioners. They are not infallible. I had been a nurse for about 12 minutes when one of the cardiologists wrote an order for 25 mg of Coumadin. I asked him if he meant to write 2.5mg and he started screaming at me to do what he said. I told him I wouldn't give anyone 25 mg of Coumadin and if he wanted the patient to have that much, he'd have to give it himself. He was belligerent and drunk but the older nurses were appalled I had questioned him. The patient didn't get 25 mg, but the doctor did get his license suspended for practicing medicine under the influence. It's MY license. MY livelihood. MY conscience if something goes wrong.
Apr 15, '17I think that's part of our job as nurses is to question, assess, and learn. The reaction you received is counterintuitive to the move in health care to provide team based care. We are supposed to be working interdependently. They seem to have an old way of thinking. Maybe you could print up some studies about modern integrative team based care. As others have said, your license and the patients safety are at risk. I work in Oregon and I would never think about not questioning an order or asking for clarification but when I worked in Idaho, I tried to remind a doctor to write an order that he said he would and my trainer stated, "You NEVER tell a doctor what to do." I couldn't move back to Oregon quickly enough.Last edit by angeloublue22 on Apr 15, '17