Can doctors go against hospital policy?

[bellehill]

We have a debate going on in my critical care unit and I would love some opinions. Our manager states that the doctors are able to write orders which go against hospital policy and we are to follow these orders. She told us that the doctor would be liable if something happened because it was their order; I disagree. Policies are in place for a reason and if we don't follow them what is the point of having them? My manager's rationale is that this specific policy was up for review and was going to be changed next month. What do you all think? Do the physician orders trump a hospital approved policy?

[bellehill, RN]

The example I have regards CVP readings from a SLIC. Our policy states that we are not to obtain CVP readings from a SLIC and the reason for this is an accuracy question. Some people agree with this and some people don't, but the policy clearly states we are not to do it. So if my patient goes into fluid overload and requires intubation or becomes dehydrated and strokes (happens often on my neuro unit) then who is responsible? The physician who wrote the order against the policy or the nurse who carried out the order?

My other point is that if we are to just follow physician's orders regardless of policy or procedure then should we stop questioning those inappropriate or stupid orders that we all see? Are we no longer advocates for the patient and their safety?

[lpnflorida, LPN]

Your example of cvp readings and what you then are do to makes sense. I can see the dilemma . Sounds like your doctors might need to look at policy and try to understand it better. Do your doctors have input into the policies in which the hospital institutes? I know they are presented to our doctors, the ones who show up at the meetings or at least read a potential policy or change there of have input. Those that don't often aren't aware of what policies might affect their own particular patients.

Thank you for taking the time to clarify. I have not ever had to work with CVP readings so I do not fully understand the meaning of the pressures I realize if they go high it can cause significant problems or too low for that matter. I will read up on it to better understand.

[FireStarterRN, BSN, RN]

We've had the issue of M.D.s wanting to do a concious sedation on a unit where it wasn't allowed and we were told not to go along with this.

I think the wisest plan is to inform the charge nurse, if you have one, or inform the nursing supervisor. Then, document that person's response and instructions.

[RN1982]

The wound vac is an excellent example. The hospital has stated that no wound vac is to be attached to wall suction. The doctor is trying to order the nurse to put the wound vac to wall suction. He can order whatever he wants but the nurse must tell him she cannot do it. She should then advise her charge nurse and I would also tell him to discuss the issue with the charge nurse. If the nurse should follow the order which is clearly in violation of established policy then if that patient has a bad outcome as a result (wound injury, etc) then that nurse is the first one responsible, the hospital would have no fault in the matter because the nurse did something that the hospital clearly says not to do. Hope that helps.

I think our CNS or nurse manager happened to see that the wound vac was attached to wall suction and made the doctor aware that this was against policy and had them order settings for the wound vac machine. WHAT I FAILED TO MENTION is that the wound vac was attached to the patient's neck where he had surgery. We were told that if was to occur again that we have the right to refuse the doctor's order.

[diane227, LPN, RN]

You are responsible for your actions, not the doctor. For example, we have a list of medications that are not to be given on our floor. When a physician writes for one of them I simply tell them that if that want to give these drugs, they will have to move the patient to a monitored area.

Now with that said, we did recently have a patient come up to our floor on an ativan drip. The pt had been on this drip for several days and was going onto comfort care. The physician specifically wrote that we did not have to any special monitoring for this patient and we carried out those orders.

We have one lady who comes in with terrible migraine headaches. She is relieved from this pain by small doses of versed. We give those small doses on our floor and just monitor her a bit more closely.

You have to make a judgment sometimes. I try to stay within hospital policy at all times and when an exception is made, clear documentation as to why has to be made. Certain medications cannot be given on our floor under any circumstance and usually the physicians are very cooperative with this requirement.

[MAISY, RN-ER, BSN, RN]

You always have a right to refuse an order that is unsafe or goes against policy. There are many instances where a physician wants medication given and I just won't do it! I always state the obvious, "if you want to give (fill in the blank), you realize you are going against policy, and or usage reason. Be my guest (handing them whatever they want.)" I also tell them I will make note of our conversation prior TO THEM DOING WHATEVER" in the chart along with physician advised not hospital policy.

99.9% of the time it is not done.

Other ideas: Call risk management, if you have a 800# for unsafe situations call them, escalate the problem to your charge RN or manager......whatever you do, DON'T DO IT BECAUSE THE DOCTOR SAYS SO!

They will always save their own butts and say something like "the nurse knew her scope of practice and did it anyway...." Believe me, I've seen it! You can be hung out to dry.

When I precept, this is nursing 101 hospital style....it's the first thing I share with a new grad. Always follow the rules, always check things yourself, never take second hand information.

Maisy

[BabyLady, BSN, RN]

The hospital where I work at doesn't permit this. Basically the hospital has a contract with the physician, "If you practice here, these are the conditions they allow it on." The physician must consult with the Physician Chair of that department and it must be approved before the physician can proceed.

The nurses at my hospital do not have to perform a single task that is against hospital policy or protocol and in fact, risk losing their job if they do. The charge nurses are required to report it immediately (as in emergency contacts) if such a thing is witnessed or if the physician is throwing a hissy fit insisting.

[RN1982]

Just remember, if the doc asks you to do something that is against hospital policy and you do it, and then something happens to the patient and you are in a courtroom and the lawyers ask "Why did you do it if you knew it was against policy?" and your answer is "Well, the doc asked me to"....

That's just not gonna fly. You will be held responsible.

[FireStarterRN, BSN, RN]

Perfectly said, Detroit.

[BabyLady, BSN, RN]

....and not to mention the hospital won't back you up and neither will your malpractice insurance, if you carry it.

A physician is not an employee of the hospital.

[ghillbert, MSN, NP]

Whenever a doc has given me a ridiculous order, I state that I'm not doing it, but he's welcome to do it himself. They usually don't. Eg. We were having trouble fitting an IABP patient into an elevator to get them to the cath lab. Dr wants me to disconnect the IABP console, take a different elevator, and meet them upstairs. Balloon off for several minutes. He says it's fine because the patient is heparinized. I said "well, I'm sure not doing that, but you can go ahead. Here's where you disconnect". Of course, then I added that we'd fit in the elevator fine if they'd just back out and go in the way I told them to in the first place. We did. No way would i follow an order that contravened hospital policy. Not worth it.

[TiredMD]

Physicians who want to go against a particular policy, as others have pointed out, should simply do what they want themselves. I have done this many times, usually in reference to "we can't give that medication on this floor". In one particular hospital, no IV narcotics other than Morphine could be given on a med/surg floor (though dilaudid and fentanyl PCAs were acceptable and required no additional monitoring). I frequently gave dilaudid myself, to the point where the floor started stocking it in their Pyxis, despite the fact that the RNs couldn't administer it.

As licensed professionals, I have never argued with or looked down on RNs who refuse to carry out an order due to hospital policy or personal comfort level. That's their right and their license.

What I have filed complaints over, however, are nurses who quote non-existent policies as a reason to refuse a valid order. I once had a nurse refuse to give an IV beta-blocker to a patient with increasingly symptomatic a-fib, claiming that it was against policy. Well, it was a telemetry floor, the patient was already on a cardiac monitor, and no such policy existed. By the time I could get the patient to the ICU, she was pretty bad off, and I pursued that complaint zealously.

I think as long as you know the policies of where you work, and explain your reasoning for refusing an order, there will be very few physicians who will have a problem with that.