Concerned..please help

[Maria1308]

Was wondering if someone could provide me with some good advice as I am concerned about something that happened at the hospital where I work.

Hx: I have been a nurse for a year now. I participated (for the first time) in assisting in a lumbar puncture on a 17 year old patient who came in with HA. They dx'd this patient with peusdotumor cerebra.

What happened: During the LP procedure, I was told to administer 2 grams of Versed iv push (1 gram at about 40 minutes apart) to the patient to help calm her, as the procedure was traumatizing.

Unaware of the policy regarding the areas Versed could be administered, I gave this med to the patient. The patient was not on a monitor, however I did take vital signs before/after the LP procedure and the patient was stable. The patient was transferred 20 minutes later to an icu for close monitoring.

Concern: After procedure, the next day word got out (apparently by my co-worker who worked with me that night, but didn't know the policy either) that the physician (who none of the nurses like) ordered me to administer Versed on my floor when it should have been administers in the PICU where the patient should have been on a monitor during administration. Now word has gotten out to everyone in my area and PICU area about what happened. Most of the nurses feel I should report the ordering physician to administration, (not only bc they felt it was unsafe but more so because they want to get this physician in trouble.

Adamant about not reporting the doctor, I felt by me reporting the event, I would also be held accountable and get in trouble bc I didn't know the policy. Well, one of the nurses who wasn't even present during the event took it upon her self to not only go to the manager of our area but also discuss what took place to the CNO (chief nursing officer). Now in my opinion, it makes it seem as if I was hiding or keeping them from knowing what happened, because I didn't report it to anyone.

Im not really sure what I should do next and it's really stressing me out.

[Zyprexa]

pt was transferred to ICU after but versed is usually administered in PICU??? which leads us all to think peds pt.

According to the OP, the patient was 17 years old. Apparently a very big 17 yr old.

I have seen some big peds pts, but none that are 310lbs!! So would you normally take an adult pt to the PICU to administer versed?

Although I think the patient was a peds patient, I'm also very confused. What unit was this procedure taking place? Was this in the ED with mixed adults and peds? Was it a general peds floor? The whole post is very concerning, especially the lack of knowledge about the procedure and medication!

The whole "2g of versed (1g over 40 minutes)" is SCARY, and I really hope it was a typo.

[twinmommy+2, ADN, BSN, MSN]

Versed given in my ED would be part of a conscious sedation protocol. It should only be given by a knowledgeable licensed person while the patient is monitored. Someone who knows versed would have questioned the orders as given by the physician. You didn't know enough to know you didn't know it seems like. You should do some research on the drug and on its effects and what an overdose of versed can look like.

[applewhitern, BSN, RN]

I would report it because it needs to be addressed. What if the next nurse gives it (or something similar) and the patient does NOT do well? Meaning the next patient might not be as lucky and has allergic reaction, quits breathing, can't wake up, or something like that. I am wondering, if the policy forbids this drug to be given in the area you were in, why was it available there? Was it in the med dispense? Anyway, pharmacy will know who pulled the med, and who gave it. The whole point of incident reports is to correct actions that could harm a patient.

[DolceVita, ADN, BSN, RN]

I would report it because it needs to be addressed. What if the next nurse gives it (or something similar) and the patient does NOT do well? Meaning the next patient might not be as lucky and has allergic reaction, quits breathing, can't wake up, or something like that. I am wondering, if the policy forbids this drug to be given in the area you were in, why was it available there? Was it in the med dispense? Anyway, pharmacy will know who pulled the med, and who gave it. The whole point of incident reports is to correct actions that could harm a patient.

These are some excellent questions. Not to escape the nursing responsibility of the OP but I have compassion for her (him? can't remember now).

I totally agree with the post about our ability to self reflect and evaluate -- it is essential. It is also something that can be incredibly fear inducing for some.

[Workitinurfava, BSN, RN]

The MD set you up for failure. MD's generally know the setting in which certain high risk medications should be given. Have you worked with this MD before?Both of you are at fault . Always speak up if you haven't done something. It is to be expected for you not to know things as you are learning as a new nurse. Do you work at a teaching hospital? I guess I am just used to the MD's and nurses openly questioning one's comfortableness and knowledge about things.

[MikeyT-c-IV]

I don't understand. If versed is not to be given in your work area then how was it available? If there is a policy in place that specifies which departments may administer versed wouldn't there be some oversight? There may be a systems issue here.

Otherwise, this would be a non-issue for me. There is a good lesson to be learned from this experience. As best as I can tell the main safety issue here is the knowledge deficit. OlivetheRN gave great advice.

[bgxyrnf, MSN, RN]

A milligram of midazolam isn't much at all in a large personal (310 lb, I believe you said). I'd put the patient on a monitor if I had one but I wouldn't trip on it. It's *not* conscious sedation and is no different than when I give a patient a bit of lorazepam prior to going for an MRI. I'd keep an eye on the patient for sure but, they have doc jamming a needle into their spine so it would be pretty obvious if their airway were to become at risk.

Reporting... well, *if* there is a policy specifically prohibiting the use of midazolam on the floor or barring LPs then yeah, it needed to be reported. Somehow I doubt that's the case. And again, this was *not* conscious sedation.

It's ridiculous to me to think that this patient should have been transferred to PICU simply for an LP with a bit of anxiolysis.

In my book, the nurses there are making a big fuss about nothing.

[Julius Seizure]

A milligram of midazolam isn't much at all in a large personal (310 lb, I believe you said). I'd put the patient on a monitor if I had one but I wouldn't trip on it. It's *not* conscious sedation and is no different than when I give a patient a bit of lorazepam prior to going for an MRI. I'd keep an eye on the patient for sure but, they have doc jamming a needle into their spine so it would be pretty obvious if their airway were to become at risk.

Reporting... well, *if* there is a policy specifically prohibiting the use of midazolam on the floor or barring LPs then yeah, it needed to be reported. Somehow I doubt that's the case. And again, this was *not* conscious sedation.

It's ridiculous to me to think that this patient should have been transferred to PICU simply for an LP with a bit of anxiolysis.

In my book, the nurses there are making a big fuss about nothing.

I agree with you about the midaz dosing not being particularly high. However, I would actually be MORE concerned about their airway because an LP was being done. Often times the patient positioning required for an LP can make airway obstruction harder to catch early. As an aside, I don't know what type of floor this occurred on, but in my peds hospital, LPs cannot be done on the floor, regardless of what drugs are given during it.

[Boomer MS, RN]

A milligram of midazolam isn't much at all in a large personal (310 lb, I believe you said). I'd put the patient on a monitor if I had one but I wouldn't trip on it. It's *not* conscious sedation and is no different than when I give a patient a bit of lorazepam prior to going for an MRI. I'd keep an eye on the patient for sure but, they have doc jamming a needle into their spine so it would be pretty obvious if their airway were to become at risk.

Reporting... well, *if* there is a policy specifically prohibiting the use of midazolam on the floor or barring LPs then yeah, it needed to be reported. Somehow I doubt that's the case. And again, this was *not* conscious sedation.

It's ridiculous to me to think that this patient should have been transferred to PICU simply for an LP with a bit of anxiolysis.

In my book, the nurses there are making a big fuss about nothing.

I have the feeling one or more of the nurses wanted to get the doc in trouble b/c of their dislike for him/her. At least that was my impression from what the OP wrote. Still think it's better to avoid that drama, even if one shares that opinion. Stick to the facts. I think 1 mg of versed is small too and not "conscious" or "procedural" sedation, but how often have we seen polices that seem silly and need to be changed? Also still think nurses need to know or check their P&P. Some of the comments here seem harsh to me, so what else is new? The take home message is to ask when you're not sure even if you have 30+ years of hard core experience. It's always OK not to know the answer, only not OK not to know where to find it.

[bgxyrnf, MSN, RN]

--- parallel response from me ---

[bgxyrnf, MSN, RN]

I agree with you about the midaz dosing not being particularly high. However, I would actually be MORE concerned about their airway because an LP was being done. Often times the patient positioning required for an LP can make airway obstruction harder to catch early. As an aside, I don't know what type of floor this occurred on, but in my peds hospital, LPs cannot be done on the floor, regardless of what drugs are given during it.

I don't work on the floor so I don't know but... any LP that's anticipated to take 40+ minutes as indicated by the original order should just be punted to IR.

[bgxyrnf, MSN, RN]

The take home message is to ask when you're not sure even if you have 30+ years of hard core experience.

To me, the take-home message is don't try to cover things up for fear of getting in trouble.

If there really is a policy barring the use of Versed on their floor, or the performance of an LP, then the OP was clearly participating in something that s/he shouldn't have. It's an issue but not one of grand import (unless the OP were already on thin ice). A quick education update, and maybe a write-up... maybe... and then it's done.

Not escalating the issue as suggested by his/her colleagues for fear of getting in trouble... now *that's* a serious lack of judgment and one which could justifiably result in termination and, if they really are pissy about it, reporting to the BRN.