Changing orders?!

[prettypaws]

I've honestly never come across this before. I work LTC. Recently, I took a late night phone order. After hanging up with the doc I realized something needed to be clarified. It wasn't an order that could be carried out at that time of night, so, I left it for days to clarify during doc's rounds. I went back after several nights off and looked up the order. Someone clarified the order,but, they ADDED to my order. They made changes to dosage,etc. However, they never signed it. To make it worse, the changed orders were never carried out and the patient died. So, it looks like I took these orders and never bothered to carry it out. I wrote it all up and left it the DON's box. Is there anything else I should do to cover myself?

[Simplepleasures]

Well I see things havent changed since Ive been out of nursing.In an LTC facility I used to work , a Nurse Manager added words to a MD order that resulted directly in the patient's death, the facility was sued, the nurse and the administration were sued , plus the facility got a huge violation. Some nurses are so cocky that they think because they have a good relationship with the MD in question or the management of their facility, the MD wont mind, or might back her up, BUT the MD in question here was no fool and despite a "good" relationship, hung her out to dry-rightfully so. The LTC facility actually tried to keep her on staff until Human Resources lawyers strongly advised them to fire her. All the nurse manager got in the way of discipline was getting fired and having her liscense get "limited" by the Regulating and Liscensing board.This patient was in her 80's ,the DOJ did not get involved in this case as they did in the other Wisconsin nurse Julie Thao's case.

[Lacie, BSN, RN]

For one thing there should have been no ADDING to your order, as it should have been written by the person clarifying as a new order particularly since there were changes. Also even if I had just hung up with the doc and needed clarification I would have called him right back for that clarification. If by chance I couldnt get it clarified I always write a note next to it with my initials that it needs clarified and who I reported it to if it's another shift that needs to finish the task out. You did the right thing in writing it up for the DON's attention but ensure that it is followed up on so as it's not repeated again by the same or others in future situations. Also make sure you have made copies of any documentation related to the incident for your own records.

[Antikigirl, ASN, RN]

When I write orders, I make sure I line it and sign it! That means I put a line so no one can write afterwards, and sign it. That signifies that that is the end of what I wrote, anything after that is someone else. (I do that with all my documentation). That is actually taught to nurses and is acceptable by most BON's!

Also, in cases like this where an order needs clarification...I document that in the RN notes for the patient, and write that as a RN order on the 1 time MAR so that it will be carried out and signed for by whomever did it. In my nursing notes I explain why I defered the clarification for day shift or what not so my rationale is understood (and doesn't look like I was passing the buck or anything).

I am sorry this happened, and I would talk to your DON about how you can stop this from ever happening again.

[banditrn]

Geez, that was so wrong! I think you did the right thing by bringing it up to your DON, but I'd keep copies of everything.

At the hospital where I worked, it would sometimes happen that an order needed to be clarified, but it was written on a separate order as 'order clarification'.

[prettypaws]

I did leave documentation all over the place that the order needed to be clarified and who I told that too. I had also "lined" the order,etc. Someone actually went back and scrunched things in above the lines. I made copies of everything. So, it looks like I did everything I could. Now, I just have to wait and see what happens. I'm so thankful this is a temp job.

[jill48, ASN, RN]

When I write orders, I make sure I line it and sign it! That means I put a line so no one can write afterwards, and sign it. That signifies that that is the end of what I wrote, anything after that is someone else. (I do that with all my documentation). That is actually taught to nurses and is acceptable by most BON's!

Also, in cases like this where an order needs clarification...I document that in the RN notes for the patient, and write that as a RN order on the 1 time MAR so that it will be carried out and signed for by whomever did it. In my nursing notes I explain why I defered the clarification for day shift or what not so my rationale is understood (and doesn't look like I was passing the buck or anything).

I am sorry this happened, and I would talk to your DON about how you can stop this from ever happening again.

This is what I do also. I treat it like writing a check; put a line at the end of what I write and sign it. If it's a really short order and only takes up a tiny bit of space (like one or two words), then I sometimes even put a big X through the rest of the order. This is just another one of those things that you learn from experience. Good luck.

[dream'n, BSN, RN]

Just be sure to keep the copies of everything, including the order. I'm sure if it ever came down to it, the fact the you documented that the order needed clarification and that you notified so and so to follow-up will cover your bottom. Also, sounds like the added portion to your order would be obvious and in a different hand-writing. I also sincerly hope that the order was not a significant one, and that it not being carried out (not for your sake because you didn't do anything wrong) was not a contributing factor in the patient's death.