Almost fired today

caroladybelle, BSN, RN · Jan 27, 2006

That sounds valid.

The second incident is pretty darn scary. Quite frankly, you should have called the MD for a more effective med after several doses of Haldol were ineffective, regardless of the amount.

Did you consult with the Charge nurse regarding the second incident? I find it difficult to understand how s/he approved giving that amount, especially if it was ineffective. It was an inappropriate order, but even had it been acceptable, most nurses of experience would have questioned it, regardless of what the "book" said. Did you look it up in the Facility's reference to see how that specific facility handle that drug?

Yes, sometimes Haldol is given in very high doses in specific cases, but most MDs prefer other, more effective drugs in higher dosing. That drug is also a "red flag" for many bureaucracies that regulate hospitals. In many places, it is considered a "chemical restraint", especially with that dosing. If the Chart was reviewed by any of them, that dosing would cause major fallout.

Especially if it was given IV. Which some facilities bar entirely.

The first one is dangerous, but also reinforces the dangers that all verbal orders pose.

Obey the restrictions. They are there to safeguard your practice and really not out of line.

Blee O'Myacin, BSN, RN · Jan 27, 2006

Sorry to hear about your troubles. How long have you been off of orientation? I have been out of school for a year now and am in a critical care area as well. I am curious as to why so much haldol was given when there were other drugs that could have been tried when it was discovered that the haldol was not effective. Many people have a refractory reaction to haldol. Was this patient intubated at the time? And about the mistake in the ativan order, if it was ordered q3h PRN, then why would the doc freak over it being given "several times" 8 hours apart?

Verbal orders are dangerous. When I am given one, I will request that the resident enter it into the computer. If you are on paper, I'd have them write it out. Be that "pain in the behind"... protect your patient AND your license.

I wouldn't quit over this. Another unit looking to hire you would look unfavorably upon this incident and the fact that you are bolting right after a disciplinary action.

As for all the OT, how much OT are you talking about? Even if you are helping the unit out of a jam, you have to take care of yourself as well. The OT rate is so tempting though...

Good luck.

dekatn · Jan 27, 2006

I would do as the previous poster stated and obey the restrictions. I wouldn't quit, just consider it a lesson learned. We all make mistakes. Good luck to you with whatever you decide.

fluffwad · Jan 27, 2006

The bottom line is: can you work in the ICU environment successfully? That is a real big first step for a new grad.

You need to seriously think about why those med errors happened. We've all made them, the point is to look at why and learn from that. I worked 11-7 shift for years and loved it, but eventually the body just couldn't do it anymore and sleep deprivation became a big problem for me ( made some pretty goofy errors too, fortunately just in the paperwork).

Are you working too many hours?

Are you getting enough rest?

Is it possible you might have become a bit over-confident, or too frazzled?

It sounds like they may have cut you a break ( but really, they didn't do you any favor by offering that to you as a new grad) and it would be better to stay and prove yourself, but not if you think you (and the patients) would be at risk.

Good luck. Hugs!

NP2BE · Jan 27, 2006

That sounds valid.
The second incident is pretty darn scary. Quite frankly, you should have called the MD for a more effective med after several doses of Haldol were ineffective, regardless of the amount.
Did you consult with the Charge nurse regarding the second incident? I find it difficult to understand how s/he approved giving that amount, especially if it was ineffective. It was an inappropriate order, but even had it been acceptable, most nurses of experience would have questioned it, regardless of what the "book" said. Did you look it up in the Facility's reference to see how that specific facility handle that drug?
Yes, sometimes Haldol is given in very high doses in specific cases, but most MDs prefer other, more effective drugs in higher dosing. That drug is also a "red flag" for many bureaucracies that regulate hospitals. In many places, it is considered a "chemical restraint", especially with that dosing. If the Chart was reviewed by any of them, that dosing would cause major fallout.
Especially if it was given IV. Which some facilities bar entirely.
The first one is dangerous, but also reinforces the dangers that all verbal orders pose.
Obey the restrictions. They are there to safeguard your practice and really not out of line.

I appreciate the input. Let me clarify: I gave 2 mg, nothing, and gave more. At some points, I gave 10 mg an hour then backed off when the patient showed less signs of agitation. There were no RESTRICTIONS for me to follow, so hard time seeing the major issue. I didnt exceed the order, and I didnt exceed the listed safe dose. How does that warrant disciplinary action?

There were no guidelines on the haldol, all I had to go on was the drug guide, and what the other nurses had said. As for restraint, the pateint was restrained and documented as such.

nialloh, RN · Jan 27, 2006

Take this as a learning experience. Watch your med's. You are responsible for med's you give, regardless as to who wrote the order. This double checking of med's won't last forever. Also, don't be afraid to ask questions. We are all there to help each other.

Good Luck.:)

DusktilDawn · Jan 27, 2006

Concerning incident #1, the big problem is that the ativan could have inadvertently been given ATC every 3 hours because you didn't write PRN.

I also agree with what Caroladybelle in regards to the 2nd incident involving haldol because she covers alot of valid points:

The second incident is pretty darn scary. Quite frankly, you should have called the MD for a more effective med after several doses of Haldol were ineffective, regardless of the amount.
Did you consult with the Charge nurse regarding the second incident? I find it difficult to understand how s/he approved giving that amount, especially if it was ineffective. It was an inappropriate order, but even had it been acceptable, most nurses of experience would have questioned it, regardless of what the "book" said. Did you look it up in the Facility's reference to see how that specific facility handle that drug?
Yes, sometimes Haldol is given in very high doses in specific cases, but most MDs prefer other, more effective drugs in higher dosing. That drug is also a "red flag" for many bureaucracies that regulate hospitals. In many places, it is considered a "chemical restraint", especially with that dosing. If the Chart was reviewed by any of them, that dosing would cause major fallout.

Fallout- Luckily I didnt get fired but now I must verify ALL medications with the charge nurse before I give them. "charge nurse, can i hang some vanc?" crap... and I am not allowed to work overtime because they felt I have worked too much and was too tired. The crazy thing is I am helping THEM out and they cut my overtime completely!!! I am thinking I will find a new job and put my two weeks in ASAP

8 months is not a vast amount of experience for ANY nurse, in fact you still have alot to learn. Your attitude in the last paragraph has me concerned about how seriously you view these instances. These limitations were put on you not only for your safety, but for the safety of the patients. It was also done in a way so that you could learn from an experienced RN. The crazy thing is you are not helping them out if you are making potentially serious mistakes. Luckily they must see potential in you as a nurse otherwise they would have fired you.

I'm sorry if I sound harsh, but I think you need to see the opportunity you've just been given.

NP2BE · Jan 27, 2006

The bottom line is: can you work in the ICU environment successfully? That is a real big first step for a new grad.
You need to seriously think about why those med errors happened. We've all made them, the point is to look at why and learn from that. I worked 11-7 shift for years and loved it, but eventually the body just couldn't do it anymore and sleep deprivation became a big problem for me ( made some pretty goofy errors too, fortunately just in the paperwork).
Are you working too many hours?
Are you getting enough rest?
Is it possible you might have become a bit over-confident, or too frazzled?
It sounds like they may have cut you a break ( but really, they didn't do you any favor by offering that to you as a new grad) and it would be better to stay and prove yourself, but not if you think you (and the patients) would be at risk.
Good luck. Hugs!

Thanks! Actually those are good questions. I am recently disengaged from my fiance, and then working a lot and not sleeping too great so those are all probably contributory.

What do you mean they didnt do me any favors by offering that to me as a new grad?

purplemania, BSN, RN · Jan 27, 2006

Besides the medication issue, which is serious as you well know, the threat of quitting because they cut your overtime is an issue. Why do you think the facility "owes" you overtime? Why not try to live off your salary and use overtime pay for extras? I sense that you are unhappy with yourself, but don't let that spill over into your practice. Any other employer would probably react the same way to all these issues, so leaving won't gain anything and will look funny to the next employer. Stick it out. Slow down. LEARN. We all make mistakes. Quit beating yourself up over it and try to calm down enough to accept the fact that you are at fault, though not intentionally, and you have been given a chance to work out your problems. Good luck. I think you just need a little time.

NP2BE · Jan 27, 2006

Besides the medication issue, which is serious as you well know, the threat of quitting because they cut your overtime is an issue. Why do you think the facility "owes" you overtime? Why not try to live off your salary and use overtime pay for extras? I sense that you are unhappy with yourself, but don't let that spill over into your practice. Any other employer would probably react the same way to all these issues, so leaving won't gain anything and will look funny to the next employer. Stick it out. Slow down. LEARN. We all make mistakes. Quit beating yourself up over it and try to calm down enough to accept the fact that you are at fault, though not intentionally, and you have been given a chance to work out your problems. Good luck. I think you just need a little time.

Its not the overtime issue that has be most concerned actually, while it is somewhat of a concern. I don't like the idea of having to "verify" ALL medications before giving them. Its a recipe for disaster. and yes, it is my attitude. I work under some not so friendly and sometimes racist people and I really like not having to ask people if its okay to take care of my patients. Its like pulling teeth to get someone to help me turn a patient even though I am the first to help someone else. It kills me that I need help to turn a patient for that reason, now I have to ask if I can give a med.....

Keysnurse2008 · Jan 27, 2006

i have been working icu for 8 months straight out of school. lets not make tjis into a "new nurses should not go into icu" thred please, that wont help me.i was called last night and told not to come in this morning to the unit. instead i should goto nursing services and meet with my manager and her manager. yikes.
1-last friday i admittedly made an error (i work icu). a patient was admitted from the floor and i wrote an order for ativan 1 mg q 3 hrs, it should have been prn, i forgot to write prn. i reported off to the night nurse about the ativan helping with pain/agitation and he realized not to give that much. the patient got several doses 8 hours apart, but the doc flipped when he saw how the order was written
2- several weeks ago, i had an extremely agitated patient who was also 350lbs. there was an order for haldol 2 mg ivp prn, no time constraint. the nurse who gave me report said she had been moaning all night and nthing could be done, and that she had proabl;y not slept in days and her solution was to close the glass door so she couldnt hear the pt moan. i felt this to be not helpful to the pt. i ended up giving some 70 mg of haldol over the 12 hour shift. i looked up the safe dosage and that falls within the safe dose. some books say 5 mg every half hour, some say 10 mg, then double until you get the desired effect every half hour stopping at 50mg. at no point did the patient have decreased resp[irations or drop her blood pressure. she fell asleep for a few hours but thats it, all in all even that much haldol was not that effective. that was several weeks ago and i guess they were reviewing the mar and somone flipped. i also asked the other nurses on the unit, including the charge if it were ok that i give that much and noone said anything other then they had not given that much before but it didnt violate the order or the corecct safe doasge. also they were upset that i didnt question the order for not havinga time constraint, which i will do in the future.
fallout- luckily i didnt get fired but now i must verify all medications with the charge nurse before i give them. "charge nurse, can i hang some vanc?" crap... and i am not allowed to work overtime because they felt i have worked too much and was too tired. the crazy thing is i am helping them out and they cut my overtime completely!!! i am thinking i will find a new job and put my two weeks in asap
thougts anyone?

i hate that you had a negative experience...but utilize this as a teaching moment...one to learn from and move on.

i dont mean to come across harsh....but ativan in a icu setting isnt such a good idea unless the patient is in like etoh dt's and you have a detox protocol that includes it. ativan...can take care of agitation if you give enough....but.....it isnt taking care of the real problem. "whats causing the agitation?"...i have found alot of times its anoxia that causes the moaning and agitation. if you are going to lay on the sedatives do not give it...do not do not do not...unless you have abgs to support the fact that the patient is not suffering an anoxic event.it could be secondary to a mi...a cerebral bleed etc etc etc.always think patient safety first...if you work a 12 hr shift you would have given 24+mg of ativan.also important is what brought this patient to the hospital ...was it a chi?if it was then sedation is not the thing they need....was it etoh issues?what was the baseline mentation?is this a terminal ca patient?the diagnosis of what brought them to you plays a huge rule of when it is "ok" to hit that ceiling of a max dose.

and haldol...omg>>>> child thats just too much. i used to work as charge in a large state mental hospital....and in all my time of caring for acute psychotic strong ( linebacker types) 18-59 year olds....i have never given that much haldol even when i had to do takedowns and place them in 5 points.these drugs take quite a while to work out of your system ...and there again...what was the diagnosis that brought them to you?if it is pneumonia....no way bc even though the sat monitor may show they are satting 95+% they may truly be anoxic. unless that md is going to give you an order that allows you to check abgs to ensure they are not anoxic....do not do it. alawys look at that pt as if they were your mom/dad/brother/sis / child...and think pt safety.

use this as a fortunate learning experience:coollook: .