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
i agree with all of the above posters. we have all made mistakes. i personnally have made some that have kept me awake at night. i think that like so many of the nurses have already pointed out, it's not the actual mistake that has so many nurses here upset, it's the attitude. the problem is that the new nurse refuses to do what so many of us have done after making an error, say I'm sorry, listen to suggestions about how to prevent the same error, and if you are a praying person, then thank God that you did not harm the pt! (i personally have prayed after making an error that no harm would come to the pt.) all hurt feelings aside, the pt is the focus. to the o.p., if you don't learn anything else, learn humility, if you don't, then you are a danger to the public!
OP, From one new nurse to another... I urge you to stop making excuses and see your part in this. You claim you "ordered" Ativan (where's the doc in this case).
You also gave a med over and over for "psychosis." I'll ask the question again, was your patient psychotic? If it wasn't effective perhaps not. BTW, Haldol is not a sleep aid/hypnotic. If your patient needed something for sleep than you should have given her something for sleep, not for psychosis.
If you don't take responsibility for YOUR lack of judgement your patients will suffer. We must all make judgement calls in all areas of nursing.
For example, I had an order for lisinopril the other day with no hold parameters for my preop hip fracture patient. My patient's BP was 100/56. The dose was within limits according to every drug guide I would have picked up and the order stated she was to get it qd. I held it using my judgement. Giving 70mg Haldol IV without consulting the MD and the pharmacist is plain irresponsible (especially since the order was illegal to begin with). BTW, why didn't you call the pharmacist?
Running away will not make you a competent nurse. Swallowing your pride will. Listen to these experienced nurses here. I sure do!
The OP's mistake was injudicious use of the drug - he/she didn't use it in a prudent fashion.
It may or may not be a legal order, but that isn't relevant to the error. But whether it is legal or not is a matter of his/her hospital's policy.
Our docs order PRN meds without time contraints all the time. So, based on what was said here, I brought this up and we had a discussion about it at work last night.
Fortunately, we live in the internet-age.
Per JCAHO's Standards - Critical Access Hospital 2006 Medication Management:
Standard MM.3.20.B Elements of Performance for Ordering and Transcribing Medications: "Written policy(ies) address the following: The required elements of a complete medication order."
JCAHO doesn't define the required elements of a complete medication order; rather, they require individual facilities to define it.
What defines a complete order is a matter of written hospital policy. Our policy: A complete order requires: Name, Location, Time and Date of Order, Drug Name, Strength, Directions for Use (e.g. Route and Frequency), Prescriber's Signature, PRN orders require qualification for use.
Because our facility doesn't specifically define 'directions for use' (it gives examples of elements of directions but not requirements for elements of directions), an order for Haldol 2mg IV PRN is a perfectly legal order.
Nevertheless, giving it 35 times in 12 hrs is still a med error. Especially since someone familiar w/ haldol would know that haldol has a tendency to 'catch' up to someone. If you gave several more doses in the meantime, not giving it time to work, when THOSE doses 'catch up' with that patient, well, I'd have an ETT handy. . .
I still think that what all this boils down to is using your head, looking at the whole picture, what your gut tells you, discussing with MD, coworkers. If something doesn't work, I personally back up, look at the whole picture, look at alternatives, causes, ask the patient/family their opinion. this comes from experience and knowing that it is patient safety, not personal appearances that matter. Not all drugs work the same on all patients. We have all had the little old lady freak out on Phenergan......
If all it took was looking something up, we could program little robots to dispense medications. Medicine is an art, not a science. The ONLY reason we are at work is to take care of a patient.....the ONLY reason.
Has anyone else checked their drug guides to see what their's say the Haldol upper limit is? I am wondering if any of them say that the upper limit is 200mg IV. As I posted last night 2006 PDR and our in-house pharmacist say max dose for Haldol is 100mg PO or IM and that upper dose is given only for peeps exibiting extreme psychotic behavior. My drug books, Springhouse and Davis, say the same thing as the PDR.
i tell ya....you have seen what haldol does to the older folks.it isnt pretty when granny is now not only anxious but she now has the strength of superman and caught her second wind!so haldol just sucks imo, the eps that can occur are awful.
you say " i am trying to understand but just cant yet"......thats why i feel like you nm has failed ya. i love having new grads in my icu...love them. but when we hire them we owe them a resposibility to ensure they have adequate mentors to clarify things with. it is also my job to frequently check on them as charge. thats my job.....and i feel like someone like the nm and the charge nurse has failed you....bc they didnt check on ya...and they were not there as a resource to you.so i do...i feel like they failed you and kinda set ya up for this.new grads are great in a icu....but when they are hired that hcf owes them and the patients the responsiblity of ensuring the framework of support for them is there.if they dont...the hcf has failed in their duty to not only the patients...but also to this op here. you went to that hcf to gain experience...where was that cnurse when ya needed her?or that nm?
haldol is just about the worst thing in the world for the elderly. very rarely have i seen good things happen with it. granted, i work in a totally different world than the icu (i'm ltc now) but its bad stuff. i've given it on a very rare occasion and less than half of those times have i seen a good result of it. it really shouldn't be the sedative of choice. as another poster said...you'll see the results of it the next couple shifts later. the eps are very bad for the elderly too. this pt was elderly? was this pt totally out of control or psychotic or were they agitated and could have benefited from a sleeper? were they in pain too?
another consideration...if this pt was elderly...the normal adult dosages aren't always appropriate either. i do realize that pts are in an icu for very accute illnesses and sometimes the meds need to be given.
to spin this tread another way.....what other choices/ options are there for sedation in the icu environment.
okay...i just reread the ops first post.......sounds like this lady was in pain maybe? moaning, restlessness, agitation.? uping the pain meds and maybe a dose or two of ativan could have helped?
After reading this entire thread, I have to say that the OP may be deflecting, and may be running away, but the bottom line is, as others have stated, she could not have made the error without others around her dropping the ball also. And I would not want to work in a hostile environment for any reason, whether it looks like she/he is running away or not. If others are refusing to help whether it be turning a patient or giving my opinion on the haldol dosage problem, I would not want to stay in that place either. I can't blame any nurse who wants to leave when they feel they are being thrown under the bus. I had situations in the past where I felt I was being ostracized by people on my unit. At times, I have stayed in the situation to see if things change, and others I just quit. Nursing jobs are a dime a dozen. But I always end up leaving eventually because our job is hard enough without having our colleagues act like grade schoolers. I don't blame her/him for wanting to leave. :stone
Well, my thought process was haldol must be a pretty damned safe drug if a dosage of 5 mg every 30 minutes is published as safe, as long as side effects arent noticed. the drug guide says 5 mg ivp every half hour is a safe dose, and that seemed to be helping the patient chill out some. If I am sitting in a bed moaning, i would hope someone would address it too. You know sometimes doctors dont really care about patiient comfort because they are not at the bedside watching the patient or hearing their complaints , so they dont really care what happens because overall I suppose it would be safer if noone ever got meds for pain or agitation. And i thought, hey I have an order, and a safe dosage , and ill run it by somone with more experience, and no objections, ok, ill continue.
I have seen a lot of "bootlegging" going on, and pleanty of people in ICUS in the hospitalS (yes plural) at least around here do a lot of chady stuff, people with much more experience then i have. That is a big part of why these docs probably dont realize what their patient's need because some other nurse is pulling phenergan or whatever else from a stash somewhenre and illegaly sedating a patient and the docs come around and see, oh, so and so look pretty confortable to me, ill just write 2 mg haldol prn..... not knowing that some jerk is giving them whatever else so they can read cosmo in peace.
The more I think about it: The only thing I think i did wrong with that haldol order, is not get a time constarint. If the order read 2 mg q 15 min for agitation, Id feel justified in doing it again, UNTIL THE DRUG BOOKS ARE MODIFIED AS SUCH!!!!!!! I WILL GO BY WHAT THEY SAY; and if i have a moaning agitated patient with haldol aloowed to be given in 2 mg increments evry 15 minutes, id give 70 again if thats what it took.
Common sense tells me that if you have a patient who is having symptoms of unrelieved pain, agitation, etc, even with frequent treatment of a medication then that medication IS NOT WORKING and the doc should be notified...
it is called being a patient advocate first of all. Drug books are not the be - all, end - alls.
I'd consider leaving the ICU and getting some general med/ surg experience. I know you didn't want to hear this but these errors could have been HUGE. You should always question orders that don't appear to be right. There should be some time written in also. Too much Haldol can cause major permanent side effects. Sounds lie the job is very stressful and even more so if you are working OT.
can i play devil's advocate?
there are some REALLY sick people on med/surg as well, some are or become critical... i think this nurse needs a refresher before she does anything!!!
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
I thought transcribed orders were to be cosigned by another RN. routine/prn - huge difference!!!
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.
There is no such thing as a stupid question. I think I'm asking stupid questions all the time. I call docs at 3am to clarify. I also check with the other RN's if I'm not sure. THERE'S NO SUCH THING AS A STUPID QUESTION. Better to ask and consult then to get everyone freaked out.
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
Yes, luckily you didn't get fired. Some ppl get fired for less. Take this as a learning experience and you wont make the same mistakes again. I used to be a "high risk infant nurse" for a "mandated" Child Welfare Agency. When I got a job in a hospital, I had such a hard time adjusting. My probationary period was extended for three months. Try and take it as a good thing. Not everyone progresses at the same pace. Experience comes with time and learning abilities. Learn and observe as much as you can because you are a new inexperienced nurse - ICU or not. Don't find a new job. Master the one you are in because you are there for a reason!!! Believe me, when you become more experienced and they trust you, they'll appreciate all the overtime you do. There's a nurse on my floor that I think is the epitamy of "nursing" and she keeps saying to me "20 years!! 20 years!!!" She makes the job look easy.
My advise: Look for the most experienced and "kewl as a cucumber" nurse you can, and watch her/him. Ask for their ideas on a situation. How do they make the job look easy? Don't pick one that spends time complaining because that's a useless skill. Look for the ones that don't complain and just do the job. Stay away from the ones that freak out every time a challenge comes their way. Don't look for the ones who run and hide when the work appears. Ask a lot of questions. I spend most of my free time asking about the stuff I have no idea about. I spend most of my time just talking. Take this opportunity as a good one. Almost like a rest break. Let your brain relax and get out of "over-drive" and learn.
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 have only been a nurse for 6 months and this seems like a scary situation to be in. Now at the hospital that I work at an order for ativan or haldol wil not be accepted by the pharmacy without a prn prescription also. Actually that is for all narcotics. If the pharmacy does get one like that they send the order back with big pretty writing that says "get prn order also".
there are some REALLY sick people on med/surg as well, some are or become critical...
Thank you! Med-surg is not the place for inexperienced nurses to "practice" until they move up to real nursing. Patients are very complex and require just as much skill as in the units; it's just different that's all.
cursenurse
391 Posts
i agree with all of the above posters. we have all made mistakes. i personnally have made some that have kept me awake at night. i think that like so many of the nurses have already pointed out, it's not the actual mistake that has so many nurses here upset, it's the attitude. the problem is that the new nurse refuses to do what so many of us have done after making an error, say I'm sorry, listen to suggestions about how to prevent the same error, and if you are a praying person, then thank God that you did not harm the pt! (i personally have prayed after making an error that no harm would come to the pt.) all hurt feelings aside, the pt is the focus. to the o.p., if you don't learn anything else, learn humility, if you don't, then you are a danger to the public!