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 guess I'm puzzled as to what the heck the drug reference is for if you aren't supposed to believe it.
Don't believe the drug reference, but ask the seasoned nurses and the pharmacist... Who is to say the seasoned nurses and/or pharmacist is more right than the drug reference?
thanks for all the input. In light of OTHER circumstances at work such as a hostile work environment etc, I think its best for me to put my two weeks in and find another job (not in that order). When you find yourself being challenged by the ntechs, and the charge nurse shuts you up when you complain about it, and then is all to happy to write you up, then I think its likely I wont be having an easy time. especially with my having one foot back in orientation. It may not be but it sure feels like a punishment. I dont see how verification of antibiotics, eye drops, scheduled PO's is going to help me. But whatever.
So, are you going to quit your job everytime that you make an error and it is pointed out? If so, you're in for a long, hard road.
thanks for all the input. in light of other circumstances at work such as a hostile work environment etc, i think its best for me to put my two weeks in and find another job (not in that order). when you find yourself being challenged by the ntechs, and the charge nurse shuts you up when you complain about it, and then is all to happy to write you up, then i think its likely i wont be having an easy time. especially with my having one foot back in orientation. it may not be but it sure feels like a punishment. i dont see how verification of antibiotics, eye drops, scheduled po's is going to help me. but whatever.
this i overlooked reading. hmmm...dont know quite where to begin here. i dont think...i can say anything that would be of any constructive value here to np2be...so i will quietly...and with great restraint....exit this thread.:stone
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.
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.
Right here is the problem since you don't see the problem. You should have questioned that there were no time restraints. You are also responsible for writing the order and if anyone else caused harm to this patient.
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!!!!!!!
If in doubt I always check with the pharmacist. My best source for drug information
oh man, how supportive everyone is. what an incredible group of nurses that reply, i am impressed with the supportive words, air of restraint practiced in order to propel young minds to achieve the stately job of nursing. :)
hmm, my first reaction brings me to wonder if the five rights of administration were considered, the basic cornerstone of patient safety. i would not be concerned with calling the md to clarify an order. and would not be concerned with calling the pharmacist (great pharmacist) prior just to get grounded when calling the md.
but don't beat yourself up, accept the knowledge you will gain,true a lot was learned in school etc., but who knows, this charge nurse may end up to be a great mentor and resource for the future.
1. right patient
2. right time and frequency of administration
3. right dose
4. right route of administration
5. right drug
the problem was there was no frequency of administration. if there is a problem you need to question it.
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.
My oh my I wouldn't want you taking care of anyone I know. I don't know how you are going to take alot of vacation time only working 8 months also. You sound like you have quite the attitude and you don't belong anywhere you can't learn from your MISTAKES. Your patient was moaning due to what? Hallucations? You patient has a mental history of psychosis? Or was your patient in PAIN? I haven't worked in the ICU for years but you are just plain scary with that attitude.
and yes, i have been keeping up with these posts, np is clearly digging a deeper hole and i can understand why the workplace is getting hostile! i'm getting hostile just reading about this mess...
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.
The experience we have had in our facility with new nurses in the ICU has not been positive.....I agree with the other postings that you should of called the MD on the Haldol order....and did you look up the Ativan order?? For if you had...you would of known that Ativan is not normally given on a regular basis vs prn. But as nurses we are not invincible and should learn from our mistakes.
KRVRN, BSN, RN
1,334 Posts
I guess I'm puzzled as to what the heck the drug reference is for if you aren't supposed to believe it.
Don't believe the drug reference, but ask the seasoned nurses and the pharmacist... Who is to say the seasoned nurses and/or pharmacist is more right than the drug reference?