advice on being written up when I dont think I should have been...

[anniegirl1988]

I was told today that I was written up for not notifying a dr about a patient situation.. here is a little of what happened.

I picked up a patient in my shift with 4 hours left to go. This pt has 3mg scheduled dilaudid Q3 and 50mg of Benadryl Q6 with orders to hold for sedations. nurse that gave me this patient had given the 0000 dose which both were due at that time.. he said that she wasnt waking up but pushed it anyways... okay so that irritated me right away because I knew the orders and had had this patient a few days before and she was A&O... so went in to see the patient and she was lethargic and not really responding just groaning. So I told my charge what happened and held her 0300 dose of dilaudid and continued to monitor. When I went in at 5 to do my nurse draw I messed with the patient did my draw pulled her up in bed blah blah blah. still only moans to answer. This patient by the way gets lots of narcs and usually dose okay. Kidney function and liver function good and vital signs good. I told my charge again that it was bothering me that she was like this and we decided to call our rapid team to see if she possibly needed narcaned or something. When I called I told the nurse So I just needan opinion at this time I am not calling this as a rapid response. She said okay and came up saw the patient and decided also that it did not need a rapid response. However she filled out her paper work which since I had only called rapid response twice before thsi and they were actually rapid responses I did not know she did not need to fill out paperwork for this visit. I however assumed it was just part of their charting. Since nothing more than just continue to monitor patient was done we did not notify the MD even more so because it was still our on call doctor and not her and she would be in in a few hours. We did leave her a note telling her hey maybe think about order changes.

Now I find out I was written up because I did not notify the Dr about a rapid response on her patient. But again I was only calling for an opinion per my charge nurse. Is it right for me to have been written up for this or should I protest it like I want to do?

[jadelpn, LPN, EMT-B]

Now that it was written up, the only thing you can do is to be mindful for future situations, and that you have learned this going forward.

Do not get into the habit of "eh, this is not a "real" rapid response". If the patient is not responding to any stimuli except for pain, then that needs to be documented, and a RR called. Which would necessitate a call to the MD for alternate orders.

If this is in your charge's hands as opposed to yours (with follow up to the MD) then I would explain that you did not realize that you needed to be responsible for calling the MD yourself, that you were looking to have another set of eyes on the patient, and (here's the important part) You were following the delegation of your charge nurse--but I would NOT say "it was not a real RR" as from what you described, it would be, and you do NOT want your critical thinking skills called into question.

This is all policy based, and yes, you did ask your charge for direction. Now you can state that you know that the follow up is up to you. Seems like charge covered herself by filling out RR paperwork. But unfortunately, you are left holding the bag. Which I am sorry that this happened to you. But again, information that you now know going forward, and be careful of bus drivers who mow nurses down. Again, "I was following the chain of command" would also be appropriate. And communicate with charge. "I am not giving patient xyz her dilaudid, as she is way off her baseline, per my assessment. I need to call a RR now. Would you come assist?" THEN if charge says "HOLD up wait a minute...." DOCUMENT this, cover yourself.

Never think you can not call a RR when a patient is unresponsive to the point you describe, and that far off baseline. And that any supervisor would tell you otherwise is doing the patient and your practice a dis-service.

[icuRNmaggie, BSN, RN]

Yes, it sounds like the pt was over medicated, or possibly had a stroke or at risk for respiratory depression, and this should have been reported at 0300 or a rapid response called at that time. Please never hesitate to call a rapid response. No one will ever fault you for calling for help. If your gut feeling is something is wrong, and even if you can not put finger finger on it, please call the rapid response. We don't mind being called we truly do not. Even if you just need another set of eyes, say I am not sure what is wrong. We are your back up. We have your back.

If you feel confident in your assessment, next time call the physician and say:

"I am very concerned about Ms Smith. She was lethargic at 0300. I held her meds. She is still very lethargic and only moans to vigorous stimuli. "

Did you assess her for signs of a stroke or respiratory failure?

Always notify the MD if there is a significant change. Make sure that someone else hears you report the information to the MD. Document well. Some of these MDs are very quick to blame the nurse when something goes wrong. Listen to your manager, ask how you could have handled this differently. Don't worry about being written up. You just want to know what is the best way to provide the best and safest possible care while working withing your faci.ity's policies and procedures. Best wishes, Maggie.

[firstinfamily, RN]

As stated above you need to practice within your facilities policy and procedures. You are ultimately responsible for the pt, not the charge nurse. You did the right thing by informing her/him of the changes of pt's LOC, and yes, most likely it was due to the medication, however, if it was not there should have been further assessment and possibly testing done to rule out stroke, or other acute event. The golden rule for nursing is CYA (cover your a**) and this includes notifying the MD with any changes in the pts condition. What if she had gotten worse? What if she had arrested? The MD was not notified with the initial changes, so he could come back on the nurse and say "but we could have done . . . . .,however, I was not notified." You were written up, just learn from this experience and grow from it. Good Luck!!!

[xoemmylouox, ASN, RN]

You should always notify the MD if there is a change in patient status. In most of the places I have worked you were always to notify the MD if medications were held due to change in status and/or V/S being out of parameters.

[sistrmoon, BSN, RN]

Please never hesitate to call a rapid response. No one will ever fault you for calling for help. If your gut feeling is something is wrong, and even if you can not put finger finger on it, please call the rapid response. We don't mind being called we truly do not. Even if you just need another set of eyes, say I am not sure what is wrong. We are your back up. We have your back.

Best wishes, Maggie.

I wish this was the attitude at my hospital. I always call my rapids and if it is obvious the patient is in trouble( systolic in the 70s, pulled out central line in groin with INR of 5 and bleeding profusely), no one questions me and is supportive. But other times(o2 sat of 60% on arrival to floor), I get eye rolls and "are you sure the probe was on correctly?" Etc. And the doctors at our facility are immediately notified when a rapid is called but they take it as an insult. I've seen nurses hesitate to call for these reasons.

[dudette10, MSN, RN]

I was trained in an environment in which RRs were not used very often because the responding docs were *******s. I now work in an environment in which RRs are encouraged. I will never again work in a hospital that treats nurse concerns about a patient with such contempt. I am now able to get the care my patients need with RRs, which is to prevent further deterioration, instead of calling one when pts are a breath away from a code.

You work in an environment like my old hospital. Your being written up for calling/not calling an RR was bureaucratic crap that only does a disservice to patient safety.

[Caffeine_IV]

I think the write will stand at this point. Just take it as a lesson learned. Report findings as early as possible. It can just be an FYI to the doctor and you can note in the chart that you addressed the assessment finding. Don't hesitate to call the RR if you have an inkling of doubt.

[been there,done it]

Are you being written up for not notifying the physician.. or not addressing the change in LOC?

Either way, you did not manage the patient correctly. Can't assume it was the narcs and just hold them. You need to KNOW why the patient is now obtunded. What were the vital signs and why are you counting on the charge nurse for direction?

[Decade1]

I remember a place and time when situations like this were treated as a learning experience and did not need to involve a disciplinary action. Sometimes the exact right thing to do so far as protocol etc. isn't clear or there's differing opinions. [Contrary to the idea that everything in medicine is reducible to an algorithm.] If someone, especially in a position of authority, has a differing idea of to interpret or implement care the issue could be discussed and taken as information about how to proceed correctly next time. I have never been "written up" (God forbid I make a grammar error) in over a decade of nursing. I wonder how long I'll continue to avoid this as people, rather than supporting one another, seem to revel in flogging each other and making an example of their errors. It's in part a trend of society (think mean girls); let's expose someone's flaws and make them weak so we look better. Also, it's just the easy, lazy thing for management. It requires less of their time than actual education and staff engagement. Now that I've stepped off the soapbox: you should have let the doctor know. It sounds like you weren't negligent. You made sure to involve the resources needed to care for the patient, but keeping the team informed is part of your responsibility. Did it require a write-up for you to understand that? Unlikely; it could have been presented in another fashion. Should you fight it? It depends. What are the consequences? Does it matter if your opinion is different from your bosses? If the write-up could interfere with your career plans I would consider a conversation, in a professional way, explaining why you think this is excessive. Otherwise, I'd let it go. IMO a place that needs to resort to frequent write-ups to address issues in patient care has much deeper issues. If you are firing/disciplining your staff with regularity you need to look at your hiring processes, training methods, and management style more closely.

[Decade1]

Something else I've learned along the way is they're peeved if you call and even more peeved if you don't call. I just call. I don't really care if the on call doc gives me attitude. Chances are I wore my big girl pants that day, and if not I just go have a nice little cry in the bathroom and a large glass of wine when I get home. Honestly, when I'm in doubt-I call. They're being paid (handsomely) to be there to take your calls. Also, as a little revenge, if you tend to be a douche about me calling you it's amazing what I can make seem urgent at 0300. I tend to call those people just a little more.

[Julie Reyes, DNP, RN]

It sucks to get a write up, but what would suck worse is if you lose a patient down the road because you don't call the provider or a RR. Remember that patient's can turn on a dime, and if you have any doubt at all - call.

It sounds like your charge nurse should have been written up as well, though, if they are going to all the trouble of doing write ups. It seems like you had informed her/him twice, so why leave them out? (I am not advocating for write ups, just pointing out something). At the very least, the CN should back you up.