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
Somewhere in this post the OP does mention that he asked other nurses, and they said they had not given that much. They apparently didn't give any guidance, and so the OP relied on only the drug book. Even with no guidance I think experienced people telling me they had never given that much would send alarm bells off in my head...
This is the critical thinking part of nursing that we are all bemoaning is lacking.
It would have been much better if the charge had said, no I've never given that much, have you tried XYZ and thought about calling the MD?
Perhaps the charge did say this, we don't know. The OP is relying on the "I was just following orders" mindset which will not fly well in a critical care setting, or any other setting for that matter.
TNNNurse has an excellent point about experienced nurses offerring help. Sometimes people ask a question and it is answered quickly, but there are underlying questions. Now, when I am precepting and working with a new nurse that asks a question that is unusual (How much haldol...)I usually give an answer, but also ask, "What is going on with your patient?" giving them an opportunity to describe the situation. Often this does save the nurse from doing something unnecessary, or even an error. By asking, I give them an opportunity to tell the whole story, and then I can put their question into appropriate context...
but on a busy day this is difficult to do, I htink we all need to make an effort to really listen to what is being said, because sometimes the actual question is not so serious, but the problem the person is struggling with is.
Asked, as in "I'm going to give a 2mg dose of Haldol, and see how the patient does, and then perhaps repeat it". Or "I am going to give 2mg of Haldol, until it works, 30 or 40 times over the next 12 hours".
If they made the first statement, especially if the Charge were busy with their own patients, or major issues, they may have said okay.
But there is a substantial difference between the first and the second.
both were sentinal events, could have caused major harm...on the #1 situation, you would figure the person coming in after you would have questioned Q3h ativan...unless actively seizing...frankly, I would have called the doc (or at my facility, I would have called you first...),
we're all learning...even at 10+ yrs, we are able to learn something.
thank you for posting your situation, we can all learn from each other
linda
Neither were sentinal events. Sheesh.
The ativan was easily corrected far before it reached the pt as a routine order instead of a prn order. It upholds the redundancy of the verification system. If you file a sentinal event everytime a med error is caught BEFORE it reaches the pt, then JCAHO needs to hire about a thousand more staff members.
And the Haldol. Apparently this was only 'caught' after the fact, when they were looking for the goods on this person. Is it an obvious error in judgement? Of course. Nobody here doubts that but the OP. But as the OP points out, the error was within the acceptable use of the drug, even if the circumstances of the particular order didn't allow such a use. The use of a drug within its parameters on a pt that wasn't harmed is not a sentinal event - even if it was an obvious 'med error'.
Let's not get extreme here.
My routine advice to new nurses is never open more than two vials, give more than 2 pills, or more than 2 PRN doses of ANYTHING without first running it by the charge nurse. That's good advice for all new nurses.
And I even dispute that not giving a time limit invalidates the order. No time limit means there isn't a time limit. Our intensivists order 2mg MSO4 IV PRN pain, Ativan 2mg IV PRN sedation, and 'name your paralytic and dose' IV PRN movement all the time. The time contraint of such a drug is 0 minutes. Under the five rights (or six if you want), the right 'time' is 'at will' in the nurses' judgment. Giving it 35 times is certainly not prudent judgment and goes beyond the intent. The intent is to use the drug to effect, not to use it beyond any measure of effectiveness. (and if you have to give it 35 times for it to be effective, then you should have long ago asked the doc for a more appropriate measure.) The med error would be the same error if the order had been written Haldol 2mg IV q 15min PRN agitation. The problem wasn't lack of time restraint, but injudicious use.
I wouldn't use a drug without a time limit anywhere but critical care. In critical care however, I have the close observation capabilities to stay on top of the sitution. No time constraints is the equivalent of titrating a gtt. Can you argue that a drip is more effective? Yes, but the intent w/ divided doses without time constraint is to simulate a gtt if necessary, but without continuous use if not mandated. The intent is to MINIMIZE its use if possible - liberal but minimal effective use. So, giving it far more often than a gtt would certainly violates the intent.
But I will say this. It only takes 1 time to see a doc verbally order Haldol 10mg IV only to have the nurse refuse to give it, and the doctor subsequently give it himself, only to re-intubate that pt 10 min later to have a healthy respect for haldol IV. I would never give more than 10 mg of Haldol IV, even in divided doses, in any 12 hour shift to anybody before I asked a doc for better control. Besides, haldol has a tendency to 'catch' up with somebody. I wouldn't want it to start 'catching' up 20mg after the fact. I'm not a fan of haldol anyway. Any night shift nurse can tell you stories of giving haldol several times to an agitated pt, only to have it finally catch up about 5am. Then, when you come back that night, the day shift nurses says 'I didn't give any, they slept like a baby all day.' Duh. Only to be awake and agitated again all night. Talk about encouraging ICU psychosis!
Somewhere in this post the OP does mention that he asked other nurses, and they said they had not given that much. They apparently didn't give any guidance, and so the OP relied on only the drug book. Even with no guidance I think experienced people telling me they had never given that much would send alarm bells off in my head...
This is the critical thinking part of nursing that we are all bemoaning is lacking.
It would have been much better if the charge had said, no I've never given that much, have you tried XYZ and thought about calling the MD?
Perhaps the charge did say this, we don't know. The OP is relying on the "I was just following orders" mindset which will not fly well in a critical care setting, or any other setting for that matter.
TNNNurse has an excellent point about experienced nurses offerring help. Sometimes people ask a question and it is answered quickly, but there are underlying questions. Now, when I am precepting and working with a new nurse that asks a question that is unusual (How much haldol...)I usually give an answer, but also ask, "What is going on with your patient?" giving them an opportunity to describe the situation. Often this does save the nurse from doing something unnecessary, or even an error. By asking, I give them an opportunity to tell the whole story, and then I can put their question into appropriate context...
but on a busy day this is difficult to do, I htink we all need to make an effort to really listen to what is being said, because sometimes the actual question is not so serious, but the problem the person is struggling with is.
Agree, the bottom line is the doctor should have been called for clarification of his order. If the OP needs to be told this, then more orientation & closer watching is needed.
And like I said, if you can give me a real contraindication for giving that amt of haldol besides the esatblished fact that the order was improper, or you have not given that much, id love to hear it. I havnt heard anything that makes me think its too much . "we have never given that much before" doesnt mean anything to me. I gave the drug, observed for s/s of hypotension/decreased resp,. and ekg changes, noted none, and gave more, all way under some of the dosing guidelines I have seen which inculde a ceilinge single iv dose of 200 mg and uo to 700 mg a day in some literature. I am trying to understand. But I cant yetr
That, IMO, is a big part of the problem. It should mean something to you. When you gain experience in a particular area, you become familiar with what is usual/customary/acceptable and more easily distinguish it from what is questionable or unusual. When experienced nurses tell you that they have never seen that before, it should raise a red flag for you to obtain clarification of the order. The "maximum safe dosage" is very often a far cry from the therapeutic effect intended by the ordering physicians (who are capable of making mistakes too, by the way) and it is up to the nurse to recognize a proper order from an improper one and when an unusual/improper order is found by the nurse, it is absolutely necessary for patient safety that the order be questioned or clarified..
Per 2006 PDR and our in-house pharmacist, the max dose for Haldol is 100mg PO or IM and that dose is given only for peeps exibiting extreme psychotic behavior. I don't think that moaning fits into that catagory. Pharmacist also said that doses reaching the 70mg range are seldom given in the acute care hospitals especially IV and that it is somewhat more common in a pschy facilities. I definatly would question the OP's resources because MY drug books, Springhouse and Davis, say the same thing as the PDR. I definatly would not go by some random internet reference. I am wondering what extraparamital symptoms this pt suffered, you know there had to be some especillay if she was elderly. I still think that the OP's refusal to admit wrong doing is scary. He/she definatly lacks the critical thinking skills needed to work critical care. I'll state again, this would have gone before the peer review commitee at my facility.
i think that your digging yourself a hole that you may not be able to get out of. the more you post the more inexperienced you sound. n my own opinion the only thing worse than making an error is not being able to except that you made an error or even agree that what you did was an error.
sorry...but i was thinking the more the op either explains the situation or replies to others' thoughts/criticisms...the more they sound like they're whining.
this is a serious matter & i think many here are concerned with the op's attitude regarding taking responsibility for their actions & formulating a plan of care to correct & fine tune their critical thinking skills. it's rather hard to take what the op is saying seriously when they seem to whine or have verbal outburst/reaction to the other replies here from more experienced nurses...of course...this is just what i'm inferring from the posts...i apologize if i'm wrong...just my observation/perception.
somewhere in this post the op does mention that he asked other nurses, and they said they had not given that much. they apparently didn't give any guidance, and so the op relied on only the drug book. even with no guidance i think experienced people telling me they had never given that much would send alarm bells off in my head...
this is the critical thinking part of nursing that we are all bemoaning is lacking.
it would have been much better if the charge had said, no i've never given that much, have you tried xyz and thought about calling the md?
perhaps the charge did say this, we don't know. the op is relying on the "i was just following orders" mindset which will not fly well in a critical care setting, or any other setting for that matter.
tnnnurse has an excellent point about experienced nurses offering help. sometimes people ask a question and it is answered quickly, but there are underlying questions. now, when i am precepting and working with a new nurse that asks a question that is unusual (how much haldol...)i usually give an answer, but also ask, "what is going on with your patient?" giving them an opportunity to describe the situation. often this does save the nurse from doing something unnecessary, or even an error. by asking, i give them an opportunity to tell the whole story, and then i can put their question into appropriate context...
but on a busy day this is difficult to do, i htink we all need to make an effort to really listen to what is being said, because sometimes the actual question is not so serious, but the problem the person is struggling with is.
the op asked other nurses their opinion *after* the fact...like during an investigation. whenever grave medication errors like the haldol one occurs...there is always some sort of after-action discussion to see where the error line & make the correction(s). the other nurses (including the cn) could've made the remark that they haven't personally given this much haldol within one shift despite the fact that it *could* possibly been given on paper.
my other thought here is who wrote the order for the haldol? was it a green resident? did they write this order based on what they thought the primary nurse (in this case...the op) wanted? i personally know that it's the primary nurses who guide the green residents in what *they* what ordered for their patients. the residents typically learn to rely on *our* recommendation & make orders accordingly. now consider having a green resident relying on a somewhat green primary nurse? well just imagine the outcome. no matter what though...in the end...it's always fall back on the person who gives the medication & in this case...it's going to be the primary nurse.
Per 2006 PDR and our in-house pharmacist, the max dose for Haldol is 100mg PO or IM and that dose is given only for peeps exibiting extreme psychotic behavior. I don't think that moaning fits into that catagory. Pharmacist also said that doses reaching the 70mg range are seldom given in the acute care hospitals especially IV and that it is somewhat more common in a pschy facilities. I definatly would question the OP's resources because MY drug books, Springhouse and Davis, say the same thing as the PDR. I definatly would not go by some random internet reference. I am wondering what extraparamital symptoms this pt suffered, you know there had to be some especillay if she was elderly. I still think that the OP's refusal to admit wrong doing is scary. He/she definatly lacks the critical thinking skills needed to work critical care. I'll state again, this would have gone before the peer review commitee at my facility.
OP's resource that she cited was docmd.com :uhoh21:
It doesn't matter what her source was-- a call to the MD for clarification of the order was warranted. Good grief, she could've called the MD at any point in that shift if she had time to go on the internet & medicate the patient so many times!!! Since when do internet resources & drug book guidelines take precedence over hospital policy & procedure-- or over good old basic nursing-- the 5R's???? Where is the common sense? Since when do we assume we can fix an incomplete order by looking things up & then deriving what WE think it means & doing it as though it were an order?? & w/no communication w/the MD? If that were acceptable, then I guess we'd all be writing our own orders based on our own perceptions. I'm sorry, but I agree that the facility is being very generous in allowing her to continue to work w/restrictions. They are hoping she will learn & grow from this; instead she is displaying arrogance & blaming.
somewhere in this post the op does mention that he asked other nurses, and they said they had not given that much. they apparently didn't give any guidance, and so the op relied on only the drug book. even with no guidance i think experienced people telling me they had never given that much would send alarm bells off in my head...
this is the critical thinking part of nursing that we are all bemoaning is lacking.
it would have been much better if the charge had said, no i've never given that much, have you tried xyz and thought about calling the md?
perhaps the charge did say this, we don't know. the op is relying on the "i was just following orders" mindset which will not fly well in a critical care setting, or any other setting for that matter.
tnnnurse has an excellent point about experienced nurses offering help. sometimes people ask a question and it is answered quickly, but there are underlying questions. now, when i am precepting and working with a new nurse that asks a question that is unusual (how much haldol...)i usually give an answer, but also ask, "what is going on with your patient?" giving them an opportunity to describe the situation. often this does save the nurse from doing something unnecessary, or even an error. by asking, i give them an opportunity to tell the whole story, and then i can put their question into appropriate context...
but on a busy day this is difficult to do, i htink we all need to make an effort to really listen to what is being said, because sometimes the actual question is not so serious, but the problem the person is struggling with is.
the op asked other nurses their opinion *after* the fact...like during an investigation. whenever grave medication errors like the haldol one occurs...there is always some sort of after-action discussion to see where the error line & make the correction(s). the other nurses (including the cn) could've made the remark that they haven't personally given this much haldol within one shift despite the fact that it *could* possibly been given on paper.
my other thought here is who wrote the order for the haldol? was it a green resident? did they write this order based on what they thought the primary
i may have misinterpreted what np2be said.the way i took it was that she had asked several people before she began giving this med.i think everyone is concerned about his/her statement that he/she would give that amt again. as i said....it is my hope that this op wrote that in haste...and didnt really mean that. so np2be....what is it? did you ask the cn and others before you gave the haldol....and did you include all the info they might need to fully answer your question?
also.....did you really mean that youd give that amt again?or was that just some misplaced emotion that made ya say that?
and for the rest of us that have seen all types working in a icu...it is not completly unbelievable( unfortunately) to believe that this op might have asked prior to giving this haldol time and time again...and was either ignored...or given a flippant response of "give whatever it takes" kinda response . if you havent worked with a bunch of imbeceles that would do that....then you havent been in nsg long enough...bc those idiots are out there( scary isnt it?)
i am probably the biggest patient safety advocate there is out there. and i am sorry...yes this op has to be accountable bc patient safety is our #1 priority here.......but i really feel like a few others dropped the ball on this too. just about every pharmacy has pyxis med systems or meditrols.......and that order has to be enetred by a pharmacist (bc even haldol is counted on most icu pyxiss systems)...and it aleets when you have retrieve d a "set amt" of that drug. like ativan- it will alery pharmacy after 12 mg have been pulled out in 2 hours.so...i think a few people dropped the ball here and id be very interested in hearing more of the story from np2be. and np2be...by your telling more of the story...you may help another new nurse that is going thru the same thing......and i think all the people who have responded to your post have answered with the spirit of being patient safety oriented....and not just "pickin". ya know...
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.
KatieBell
875 Posts
Somewhere in this post the OP does mention that he asked other nurses, and they said they had not given that much. They apparently didn't give any guidance, and so the OP relied on only the drug book. Even with no guidance I think experienced people telling me they had never given that much would send alarm bells off in my head...
This is the critical thinking part of nursing that we are all bemoaning is lacking.
It would have been much better if the charge had said, no I've never given that much, have you tried XYZ and thought about calling the MD?
Perhaps the charge did say this, we don't know. The OP is relying on the "I was just following orders" mindset which will not fly well in a critical care setting, or any other setting for that matter.
TNNNurse has an excellent point about experienced nurses offerring help. Sometimes people ask a question and it is answered quickly, but there are underlying questions. Now, when I am precepting and working with a new nurse that asks a question that is unusual (How much haldol...)I usually give an answer, but also ask, "What is going on with your patient?" giving them an opportunity to describe the situation. Often this does save the nurse from doing something unnecessary, or even an error. By asking, I give them an opportunity to tell the whole story, and then I can put their question into appropriate context...
but on a busy day this is difficult to do, I htink we all need to make an effort to really listen to what is being said, because sometimes the actual question is not so serious, but the problem the person is struggling with is.