New nurse still on orientation and first med error? - page 3

Let me just start off by saying im extremely cautious about giving meds and checking and double checking them because I dont want to make a med error but on my last shift a patient got up and... Read More

  1. by   Esme12
    Quote from Susie2310
    Esme, you are a highly trained and experienced nurse. There is a big difference between someone like you initiating a treatment like this and someone with significantly less training and experience. Also, for many reasons, not all nurses are competent in their practice. Personally, I far prefer to err on the side of caution for the patient's sake.
    What you say is very true. I have seen some pretty alarming things in my 34 years that make me shake my head and wonder WHAT WERE THEY THINKING???? While I agree, for the most part, MD order for electric hot pads/clod packs is routine litigation has made it a necessity.
  2. by   tyvin
    Quote from Susie2310
    Esme, you are a highly trained and experienced nurse. There is a big difference between someone like you initiating a treatment like this and someone with significantly less training and experience. Also, for many reasons, not all nurses are competent in their practice. Personally, I far prefer to err on the side of caution for the patient's sake.
    Unfortunately; just because one has passed the NCLEX and actually was somehow able to get the actual RN license in hand and then to have been hired somewhere does not make a competent RN by any stretch of the imagination. I don't know how some do it but I've worked with some RNs I wouldn't trust with a glass of water let alone a warm compress.

    After my first year working I was in shell shock. I could not understand how some of the RNs I worked with got their licences...how? It got to a point I was afraid to go to work. I quit after I was called in the office because another RN had complained that I verbally assaulted her. "What...me!" Come to find out that while this certain RN and I had been doing a wound drsging change on a stage IV ulcer I had the camera and the other RN had the resident on the side with the coccyx bare so I could take a picture of the wound. As I was looking through the camera lens I told her to remove the leftover gauze inside the wound. The RN responded that it wasn't gauze when at that point I realized it was bone and in a small voice I said that I detested such wounds. Long story short that RN didn't know what detest meant and thought I was calling her a bad name. Why would I do that? I didn't ever know her...anyway the meeting ended with my DON telling me to not use big words around the staff. Seriously!

    It got to the point that I was examining everything I was about to say. Oh forget it; I got an offer from another job and took it. LTC was not a good fit or me. When we all have the same educational requirements in order to be a licensed RN; that's when I think we'll stop seeing such discrepancy among the RN population.
  3. by   Hygiene Queen
    Quote from tyvin
    Long story short that RN didn't know what detest meant and thought I was calling her a bad name. Why would I do that? I didn't ever know her...anyway the meeting ended with my DON telling me to not use big words around the staff.
    Well, since that nurse didn't know "big words" like detest, then I would have smiled brightly and told her she was a "cretinous and puerile imbecile".
    Last edit by Hygiene Queen on Aug 2, '12
  4. by   Tragically Hip
    Quote from tyvin
    When we all have the same educational requirements in order to be a licensed RN; that's when I think we'll stop seeing such discrepancy among the RN population.
    If you're talking about the ADN vs. BSN think — I think there's a lot more to the competency issue than that. Or are you talking about making a master's in nursing the the minimum educational requirement?

    Now than many nursing schools have turned into an NCLEX cram course with clinicals, is the NCLEX too easy? Has it always been? Are there other overarching issues?
  5. by   myoglobin
    Several points come to mind here: I am far from certain that you would need an order in order to initiate a warm compress. Absent, a hospital policy I would tend to believe that one is not needed. Certainly, at my hospital calling an MD for that (especially in the middle of the night) would likely get you written up. Second, even if you obtained an order I'm not sure that would have much effect on patient safety. Whether or not an MD orders a treatment, doesn't change the need for assessments. Stated differently a doctors order doesn't have one iota of affect on whether or not it is applied, and assessed in a safe manner. Three, although "write ups" in good organizations are indeed intended to be non punitive often in the real world they are anything but. Indeed, they are often used as tools or personal vendettas against those with whom people disagree. I am aware of one nurse who was confronted by her manager with over 50 write ups against her written by her charge nurse, none of which she had even been notified about (until that moment). This charge nurse had (and still seemingly has) the habit of writing up people without so much as saying a word and then "using it against them" at a future date when a bigger issue presents.
  6. by   Bringonthenight
    Quote from Esme12
    In America we have a very litigious society.....and some of the male MD's feel nurses are not capable of a "medical order. Depending on the facility.......We can apply warm moist clothes for IV starts etc....but for treatment or if it is electrical? That's a MD job....
    What's an electrical treatment? In Australia, or at least the places I have worked, nurses can "nurse initiate" paracetamol and saline nebulisers. Heat packs and cold packs are not considered a medical prescription.

    I'm interested to know if a patient desaturates do you need a medical order for o2 before you apply it?!
  7. by   Elladora
    We have standing orders for ice and heat packs. If we see a need, we can administer these to a patient on a prn basis. (Thank God!)

    But to answer your question, yes you can be written up even if a patient is not harmed. I wrote up THREE med errors tonight.

    1 - pills prepared for a client who then left the med room before they were administered. Pills were not dispositioned. No one was hurt, but definitely a med error. (In our facility)

    2 - a client is on an antibiotic. He is to receive 2 pills each time. Tonight he should have been done with his dosage but had 3 pills left in the bottle. Someone either missed a dose, only gave 1 pill instead of 2 (most likely) or pharmacy messed up (least likely). Again, no harm was done to the patient but it was a med error.

    3 - a client has a new med order that started the 3rd. Someone signed off on the med on the 2nd. As the med wasn't even in the facility then, obviously the patient didn't receive the med and no harm was done but again, a med error.

    No one will lose their job over any of these, but they will have a write up in their file. (We tend to use med errors as a learning opportunity).
  8. by   Esme12
    Quote from Bring On The Night
    What's an electrical treatment? In Australia, or at least the places I have worked, nurses can "nurse initiate" paracetamol and saline nebulisers. Heat packs and cold packs are not considered a medical prescription.

    I'm interested to know if a patient desaturated do you need a medical order for o2 before you apply it?!
    Heating pads, cooling blankets, ice machines for post op knees. They all need MD order. Even an ice pack in an ankle or a hot pack on the arm can cause skin damage and problems with burns/frost bite need an MD order. If the patient gets burned and the nurse didn't "get an order" or "let the MD know" she is solely liable and "practicing medicine without a license" The MD of course would always say..."I had no idea....it I had know I would have never allowed.....blah,blah,blah."

    Yes we can put on O2 for to not apply O2 can cause the patient harm.....but you must immediately call the MD and get an order. Our insurance reimbursement "system" also requires that the "MD" (PD/NP) write an order for without an order there will be no reimbursement.

    Tylenol must have an order and that is a "medicine" (even though it is over the counter) for it the patient got too much tylenol and got liver failure OR died of sepsis because the temp was treated and the MD not notified so he can do "the right thing".....

    Crazy isn't it???????
  9. by   Susie2310
    Quote from Esme12
    Heating pads, cooling blankets, ice machines for post op knees. They all need MD order. Even an ice pack in an ankle or a hot pack on the arm can cause skin damage and problems with burns/frost bite need an MD order. If the patient gets burned and the nurse didn't "get an order" or "let the MD know" she is solely liable and "practicing medicine without a license" The MD of course would always say..."I had no idea....it I had know I would have never allowed.....blah,blah,blah."

    Yes we can put on O2 for to not apply O2 can cause the patient harm.....but you must immediately call the MD and get an order. Our insurance reimbursement "system" also requires that the "MD" (PD/NP) write an order for without an order there will be no reimbursement.

    Tylenol must have an order and that is a "medicine" (even though it is over the counter) for it the patient got too much tylenol and got liver failure OR died of sepsis because the temp was treated and the MD not notified so he can do "the right thing".....

    Crazy isn't it???????
    Esme, I just wanted to express my thoughts re your last two paragraphs, because I differ from you in that I don't feel it's crazy that an order is required for O2 and Tylenol. O2 that is not given knowledgeably with appropriate patient monitoring can be harmful i.e. COPD patients. With tylenol, there are good reasons not to give without an order too; if a patient has renal failure or an infection (your example of sepsis) one would not want to jump in and give tylenol. My husband has had acute renal failure with sepsis: I am very glad a nurse didn't give him tylenol. My point is that the requirement for orders to give O2 and tylenol are there to protect patients. I do not feel diminished as a nurse because that is the case. Not all nurses fully understand the contraindications for giving O2 and tylenol, or really understand the monitoring that is required with giving O2. You mentioned in your earlier reply that you have seen some things that have caused you to shake your head as far as care given by nurses. I am glad that orders are required for O2 and tylenol, and heating pads/ice machines etc. for the sake of patient safety. And I know that yes, of course some nurses give incompetent care even with doctors orders, and yes, some doctors are incompetent.
  10. by   Esme12
    Quote from Susie2310
    Esme, I just wanted to express my thoughts re your last two paragraphs, because I differ from you in that I don't feel it's crazy that an order is required for O2 and Tylenol. O2 that is not given knowledgeably with appropriate patient monitoring can be harmful i.e. COPD patients. With tylenol, there are good reasons not to give without an order too; if a patient has renal failure or an infection (your example of sepsis) one would not want to jump in and give tylenol. My husband has had acute renal failure with sepsis: I am very glad a nurse didn't give him tylenol. My point is that the requirement for orders to give O2 and tylenol are there to protect patients. I do not feel diminished as a nurse because that is the case. Not all nurses fully understand the contraindications for giving O2 and tylenol, or really understand the monitoring that is required with giving O2. You mentioned in your earlier reply that you have seen some things that have caused you to shake your head as far as care given by nurses. I am glad that orders are required for O2 and tylenol, and heating pads/ice machines etc. for the sake of patient safety. And I know that yes, of course some nurses give incompetent care even with doctors orders, and yes, some doctors are incompetent.
    I completely agree with you.......I was responding to a nurse from Australia and by their standards what we do is crazy. The medicine in the US is very different and seems so crazy to those in another culture. I'm all for calling the MD. I have called MD for 34 years. That's what they get paid for.......I have never felt diminished as a nurse for calling the MD to make him do his job.

    I am sorry your husband was so ill.....I hope he has made a full recovery. That must have been a terrifying experience foryou and your famly.

    Shaking my head at the care by some nurses would have more to do with not calling the MD or burning a patient with a heating pad and as the manager/supervisor.....explaining this to the family.

    We agree with each other 100%....call the MD that is what they get paid the big bucks for.
    Last edit by Esme12 on Aug 6, '12
  11. by   Susie2310
    Esme, thank you for your reply. I am happy that we are both in agreement. I also really appreciated your kind words in regard to my husband. Yes, it was terrifying. We were very fortunate.
  12. by   dudette10
    Quote from Elladora
    No one will lose their job over any of these, but they will have a write up in their file. (We tend to use med errors as a learning opportunity).
    Where I work, there is a difference between a "write up" and an "incident report."

    In the very few incident reports I have done, my narrative included a chronological explanation of events without names. If risk management wants to know "WHO DID THIS?" they should be smart enough to figure it out from other parts of the med record. I do it this way because incident reports should be nonpunitive, and it is intended to point out system errors. With the way I write incident reports, RM and the NM will have to do the work to make it punitive, if they so desire.

    A write up is a reporting of another nurse's error with names/events and is punitive. If the write up of which you speak goes in the nurse's file, that's not an incident report at my facility, and it does nothing to point out system errors. Not sure how your facility does it.

    ETA: Every time I've written an incident report, I've always told the nurse who was involved in the error, although the report itself never mentions the nurse, just as a heads-up. I would hate to be blind-sided by something, and I won't put a colleague in that position.
  13. by   dudette10
    Quote from Susie2310
    With tylenol, there are good reasons not to give without an order too; if a patient has renal failure or an infection (your example of sepsis) one would not want to jump in and give tylenol. My husband has had acute renal failure with sepsis: I am very glad a nurse didn't give him tylenol.
    At the risk of sounding clueless, I have to ask why renal failure and sepsis would be a contraindication to Tylenol. I've been googling, and there are plenty of links to acute hepatic failure, but not acute renal failure. (There are some links suggesting--not proving--that long-term Tylenol use can be a contributing factor in chronic renal failure.) In addition, there are order sets for sepsis that include Tylenol as an analgesic choice.

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