Am I at fault here?

[SarahRN2010]

I had a situation come up at work yesterday and I wanted to get some feedback from some fellow nurses.

I work night shift 7P-7A in the hospital on a tele unit. I received in report that one of my patients had had a bowel movement during the day shift and was incontinent. Upon assessment of the patient I asked them if they had a BM that day and they said yes, 2 of them. There was a BM documented in the computer for that day at 1130 am. While doing my 24 hour chart checks at 1am I came across an order written that day at 1430 that stated "Daily tap water enema until patient has good BM." I never received in report that this order had been written, and the day shift nurse had signed it off. I did not administer an enema because the pt did have a BM that day.

When I came back into work the next night I had a email sent to me from the charge nurse that day stating that the MD was very upset that this pt never received an enema and the pt still has not had a BM. It is clearly documented that the pt did and the pt even said so herself. Am I at fault here? The pt had a BM which is why I did not administer it. Personally, I think the Drs order is a little unclear in the first place.

And to make it even worse, the charge nurse sent a copy of the email to my manager. I am a new grad and that really made me feel awful. Now I am afraid that my manager is going to think I am incompetent...

[FLArn]

I think the problem may exist with differing definitions of 'good'. Maybe the BM charted was a small or medium BM and the doctor was looking for a Large. I have worked places where a small BM did not count as a bm since some people count smears as smalls. Also this is further confused by the way BM's are classified my Medium may be your Large. Much easier to chart on urine 600cc is 600cc!

[nurse678]

Hey I'm a new grad too. I wouldn't have administered the enema either! Clearly the order was written on dayshift so did the dayshift nurse administer one? She should have mentioned something about it in report. If a BM was charted, how are you supposed to know if it's good or not? That order is not appropriate in my opinion. I hope everything works out for you.

[Horseshoe, BSN, RN]

I think the order for an enema until patient has a "good" BM is ridiculously vague. I doubt I would have given the enema either, particularly as the patient claimed to have had not one, but TWO bowel movements. However, I would have charted exactly that on the MAR when documenting that the enema was not given. How could they argue with that?

Secondly, on my unit, the party responsible for giving the enema would be the day shift nurse who signed off the order! Why is this nurse off the hook?

[FancypantsRN]

Unfortunately, it doesn't matter whether day shift told you about it or not - once we receive the patient, it is our responsibility to check the chart and ensure the orders have been done. Just a word of advice, I always eyeball my charts before accepting report - so I can ask about new orders. Everyone is different, but me - I prob would have either given it (in the AM since you didn't see it until 1 am), or called the doc in the morning and tell him the patient did not receive it yet, reported having a BM but I didn't witness it, also telling him how the bowel sounds are. Does he still want the enema given?

[RNTOBE_1970]

We would pull our charts for report, and do a check with off going nurse, then both nurses would sign off.

[Aprileyes]

Hello,

First nursing is 24/7, treatment is not specific to the shift that receives or notes the order. Second if you have a question about an order, whether or not you are the one receiving it or administrating the treatment, always call for clarificiation. This will give the option to update the MD regarding the patient's BM and provide clarification or revision to the current order. Most importantly when you get report always ask if there are any new changes or orders as part of your shift report. Finally if a medication error occurs please take accountability, make sure the patient is not at risk for harm. Contact the MD, and notify your manager regarding the incident. As a nurse your primary concern is patient care. Please remember nurses are just as human as the next guy, and mistakes are made, use your resources such as your manager and the treating MD. Everyday is a learning experience. I hope this helps.

[Horseshoe, BSN, RN]

We would pull our charts for report, and do a check with off going nurse, then both nurses would sign off.

That's a good point; in report, both outgoing and incoming nurses go over all new orders. You can bet, though, regardless of whether nursing care is a "24/7" and not shift dependent, if I received an order for an enema early in the day and had not given it, the oncoming nurse would want to know why not. We do not leave noted orders undone unless there is a clear reason for it, and many times there could be with regard to timing of meds. But it would not likely just fall through the cracks like that, and certainly the night nurse would not be hung out to dry for it.

[GHGoonette, BSN, RN]

I don't know what the hierarchy is like there, but that kind of situation would elicit some well-deserved snark from me. I would never let the charge nurse get away with it, nor anyone else who accused me unfairly. It all depends on how firm you are on your ground...

How oriented is the patient? Can you rely on her assertion that she had 2 BMs that day? You say one was charted-did it mention good BM?

My email reply to the charge nurse, and CC'd to the UM with the original letter, would read as follows:

"Thank you for your letter informing me of my 'oversight' in not having administered water enemas to said patient. I would like to point out to you that there was no way I could have known the prescription existed, because you did not see fit to inform me of it. If I, on my own initiative, had not looked through the patient's chart, I would not have been aware of it at all, seeing as the order was written at 14h30, 4.5 hours before I came on duty. I would also not have found out (which I did-again using my own initiative) that the patient had, by her own admission, backed up by apparently incomplete information on her chart, already passed 2 BMs that day. It did not seem appropriate to me to subject her to the discomfort of an enema, when by that time the problem seemed to have resolved itself.

A small question remains; if the order was written at 14h30, how come there was no record of enemas being given by day staff?

If the Doctor has any further complaints to make, by all means refer him to me; I shall explain to him the sequence of events as I have described them in this reply.

Yours sincerely, etc etc "

But that's me-I don't know if you feel comfortable ruffling that many feathers....

[FancypantsRN]

and forgot to say SarahRN - just try not to beat yourself up over this stuff. It's good to learn from, but I don't know how many times I was burned by this in the beginning, and on a few occasions forgot to mention something in report to the next shift and had to call on my drive home. It happens! Just learn from it and add it to your list of things to look out for : )

[systoly]

For the complaint by the MD/charge nurse to have any validity at all, the patient should have had an enema at the very time the MD first c/o or become upset. If this was not done, then there is absolutely no basis for a c/o.

[hecallsmeDuchess]

Usually when I hold a medication or an order to give something, I make sure to call the ordering doc to let them know why and also to document. Since the pt stated she had 2 bowel movements, I would not have given the enema especially if the pt is oriented but the only difference is that I would have notified the doc and documented what happened.