Almost fired today

[NP2BE]

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?

[KatieBell]

Those are scarey mistakes. I try very hard never to take verbal orders for the very reason that they can be misunderstood easily.

If it had just been the lorazepam, I imagine it would not have raised so many red flags, but the thing is with a dosage that is larger than what is normally given- it is best to call the MD and say- gee the haldol is not helping mr Jones do you think there is something else we can do for him....

You can also call the pharmacy for medication help. It is a fine line- what you describe about the haldol is that you were just following orders- and youhad no restrictions and couldn't find any, so you just continued to follow orders. You obviously realized that this was a big amount because you asked some other nurses about it, but the key thing to do at that point would have been to think beyond the order and think about getting a different order, or discussing with the MD or Pharmacy why the patient was not responding to the haldol.

Let me tell a story:

In the ED we once did concious sedation with Ketamine on a kid. The kid was not very still even with ketamine and the MD kept asking me to give more. I gave more for a while, and then it started to seem to be a huge dose. SO I looked in our guidelines, while monitoring the patient, and found NO guidelines for a safe amount to give. I immediately called the charge RN and he came and we discussed this (All while still monitoring the pt and trying to get his head sutured up without him moving.) We concluded that I had given enough. I made the MD ordering the med responsible to now give the Ketamine. I continued to monitor, but documented that I had refused to give any more, and who was giving the drug. It took forever for the kid to wake up and be able to go home. The next day I was off and went to talk to the manager. I was commended for refusing to continue to medicate at a very high dose, restrictions were placed on the use of Ketamine for physicians, and new guidelines were put in place for the use of that particular medication....

Now, I could have just given the med, because the physician was right there, but I refused. It may have saved my nursing license and definitely enhanced my reputation on the job....Nursing is more than just following the order, it is really thinking about what is going on.

I also agree that doing a bunch of overtime when you are making errors, is not going to help you. Also starting a new job when you are basically "running" from this job is not a good idea at all. You may want to stick with it for a while, and explore your options at some other places, but don't quit because of that...hang in there...

[Dayray, RN]

To me, forgetting to write PRN at the end of an order is worth mentioning but something we all have done. You just have to make a mental note and effort not to do it in the future. It could be a big deal but really it's not that bad.

The second mistake with the haldol is more complicated and more troublesome. Having worked in IUC and now working in L&D (believe it or not there are allot similarities in terms of autonomy and personal responsibility) I know that its sometimes hard in the beginning to know what you should take it upon yourself to decide. The order wasn't very specific and it's good that you did look it up however we both know the doc didn't intend for it to be given the way that you did.

I know that you were just trying to get the med to do what it was supposed to. Still you went outside of the gray area we all walk (in terms of decision making). You should have called the doc and asked for an order that would have fit the need you were trying to fulfill.

I don't think you should look for another job because allot of places would have fired or reported you. It sounds like this place likes you and they are just trying to correct your training.

You'll do okay if you choose to take this as a learning experience. I'm sure they let you have overtime and stop having the charge nurse double check on you after a short time. Be careful not to let pride blind you. You sound like a good nurse but I have seen many go down the wrong road because they didn't want to admit when they were wrong. I hope things go well for you.

[NP2BE]

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: .

i realize by what everyone is saying that this is off the map for haldol dose, but then do the variuos drug books need to be updated????? what is the point of having a drug guide if the info in it is useless!!!!!!!

[meownsmile, BSN, RN]

I dont know that the order for haldol was entirely wrong, i think the issue is why you didnt recognize the medication wasnt being effective and call the doctor for a different order long before you administered up to 70mg.

As nurses we have to use our judgement and question whether a medication is the right one based on patient outcome.

I dont work ICU,, but work acute care and see patients that get ativan, but i think if i were giving it to a patient that was agitated, and there had been no affect after the 2nd or 3rd dosing i would have been on the phone asking for something different and reporting the lack of theraputic response by the patient.

Im glad you didnt get fired although i DONT think it would have been justified anyway. And i hope you dont bail on them for another job. See it as a learning experience, a time to collect your thoughts get some extra rest and move on. Dont let this one incident keep coming back to haunt you. Did they give you a time frame for a re-revaluation of your performance? I sure hope they did,, if they didnt id inquire and get it in writing. There has to be a point where you get out from under the microscope.

[fluffwad]

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

When I was in school our instructors warned us about taking a first job that seemed to be an usually great offer. There was one place that had a reputation for offering head nurse positions to new grads. That's not an easy job, its the sort of job that most places would want an experienced nurse to fill.

Why would they offer that kind of job to a new grad? It that case it was because no one else would have any part of it because of the way the facility treated its management people and the demands they put on them.

When I moved to Ohio, I got a great offer from a facility that was just overjoyed to get a nurse with 10 years of experience. I thought it was odd, but I needed a job right away so that I could get the mortgage on the house we'd agreed to buy. Found myself working as the only licensed nurse on a neuro unit with 3 GNs.

Obviously, I don't know anything about where you work, but I can't help but be suspicious of a place that would put a new nurse in a job that intense.

[NP2BE]

To me, forgetting to write PRN at the end of an order is worth mentioning but something we all have done. You just have to make a mental note and effort not to do it in the future. It could be a big deal but really it's not that bad.

The second mistake with the haldol is more complicated and more troublesome. Having worked in IUC and now working in L&D (believe it or not there are allot similarities in terms of autonomy and personal responsibility) I know that its sometimes hard in the beginning to know what you should take it upon yourself to decide. The order wasn't very specific and it's good that you did look it up however we both know the doc didn't intend for it to be given the way that you did.

I know that you were just trying to get the med to do what it was supposed to. Still you went outside of the gray area we all walk (in terms of decision making). You should have called the doc and asked for an order that would have fit the need you were trying to fulfill.

I don't think you should look for another job because allot of places would have fired or reported you. It sounds like this place likes you and they are just trying to correct your training.

You'll do okay if you choose to take this as a learning experience. I'm sure they let you have overtime and stop having the charge nurse double check on you after a short time. Be careful not to let pride blind you. You sound like a good nurse but I have seen many go down the wrong road because they didn't want to admit when they were wrong. I hope things go well for you.

I suppose you are right about the intentions of the order and I probably new it. They sure dont make it any easier when they give such an order, its a sunday, and they dont want to hear from you about agitation. but that is no excuse. Just not looking foward to going back to the unit at all right now. And I am not looking foward to getting my butt chewed by the pulmonologist either but I have been told that is probably coming. ( major restraint of tongue will be in order).

[QuigRN]

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.

You need to know that a chemical restraint is different from a physical restraint. Haldol is a chemical restraint therefore this patient was "double restrained".

[NP2BE]

I dont know that the order for haldol was entirely wrong, i think the issue is why you didnt recognize the medication wasnt being effective and call the doctor for a different order long before you administered up to 70mg.

As nurses we have to use our judgement and question whether a medication is the right one based on patient outcome.

I dont work ICU,, but work acute care and see patients that get ativan, but i think if i were giving it to a patient that was agitated, and there had been no affect after the 2nd or 3rd dosing i would have been on the phone asking for something different and reporting the lack of theraputic response by the patient.

Im glad you didnt get fired although i DONT think it would have been justified anyway. And i hope you dont bail on them for another job. See it as a learning experience, a time to collect your thoughts get some extra rest and move on. Dont let this one incident keep coming back to haunt you. Did they give you a time frame for a re-revaluation of your performance? I sure hope they did,, if they didnt id inquire and get it in writing. There has to be a point where you get out from under the microscope.

I think they may have said 60 days, I dont know if I can deal with that for 60 days. i can deal with no OT for 60 days, (but i bet any amt of money they will be asking me to work OT in 20 anyways if not sooner) the "med verification" thing I dont know about. i wont lst 60 days wiith that. I may be using a lot of vacation time here soon.

[caroladybelle, BSN, RN]

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.

The fact that you do not see how this warrants disciplinary action, is probably quite bluntly why it does.

And I know that sounds harsh, but what you did was dangerous and if you are going to succeed as a nurse, especially as an ICU nurse, you need to recognize why they are worried.

First, an order with no parameters, such as, "Haldol 2mg IV PRN until effective"..in most facilities, and per legal issues is not an ACCEPTABLE legal order. JCAHO would have a field day with it. Before it was used ESPECIALLY repeatedly, it should have been clarified.

Second, it does not matter what the drug guide says. What matters is what the Policy and Procedure Guide of your facility says? What did it say?

Third, it does not matter what "other nurses" said, did you check with the Unit Manager or the Charge or the ADON? They will be the ones that bear some responsibility. Did you talk to the PharmD (not the Pharm Tech/Asst)?

The fact that you have to check all meds through the Charge leads me to think that you did not check with them. But I could be wrong.

What were the positions of those you consulted with, were they long time ICU nurses or new to that ICU/any ICU?

I will tell you that after 12 years of nursing, I know few nurses that would even attempt to give that much Haldol, IV in 12 hours, regardless of orders. Haldol is a lousy sedation drug. They would have called to get a better sedative and clarified the order after maybe maxing at 10-20mgs, if not before. And we give major doses of MSO4/Ativan gtt.

They are calling in question your judgement and trying to give you some guidance. And successful ICU nurses are required to have very careful honed critical thinking, good instincts and be capable of a lot of autonomy, looking for guidance when necessary. You have not displayed that, successfully, and they are trying to lend you safe guidance to develop that skill.

[caroladybelle, BSN, RN]

I think they may have said 60 days, I dont know if I can deal with that for 60 days. i can deal with no OT for 60 days, (but i bet any amt of money they will be asking me to work OT in 20 anyways if not sooner) the "med verification" thing I dont know about. i wont lst 60 days wiith that. I may be using a lot of vacation time here soon.

That, love, is pride.

And as you know, pride goes before a Fall, and in the case of nursing that Fall could kill someone.

Do not let pride keep you from succeeding in nursing or accepting the assistance that you need to develop prudent practice.

Quiting over this will not help your reputation. Deal with the restrictions and learn from them.

[nursenatalie, ADN, RN]

After making a mistake like this your first priority should be to find ways to decrease the likelihood that you will make the same or similar mistakes again. If I write an order and transcribe it to the MAR then I will have another nurse check or note the order. Just because you were within the constraints of the order as written it was written incompletely. Our pharmacist will usually give us a call if an order is written incompletely. If I receive an order such as 1 mg ativan iv q 15 minutes until calm then I will ask the doc for a max amount ie; 10 mg. Frankly you seem offended for being reprimanded and that is a dangerous situation. The fact that no harm was done doesn't change the fact that it was a mistake just consider it a valuable learning experience. You seem more upset about the limitations your nursing supervisor has placed than you are about the fact that you made an error. Everyone will make mistakes but not everyone is humble enough to learn from them.

[spidermonkey]

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.

I agree. Here's a different twist though- when I was a new RN (in charge of a Med/Surg unit) an office nurse called me w/orders for IV Potassium. I refused to take the order from her- the dr. got on the phone & reamed me out for not taking an order from his nurse b/c "it's just as good as an order from me!" But he angrily gave me the order. Then the DON came up to the floor & had a "chat" w/me & told me, while the office nurse didn't USUALLY give medication orders, if I knew that nurse I'd know she was reliable! No disciplinary action, and I worked in that position for 5 yrs (I resigned b/c I moved out of state) w/out any further orders from another nurse!