Crap, I should've paged the MD.

GilaRRT · Aug 1, 2008

Ok, did you talk to the doc the next day? Did the nurse who questioned you talk to the doc? Somebody let the doc know, yes? Possibly a very important bit of information. A bulls eye rash does not present with every case of Lyme disease. In addition, other diseases can be transmitted by tick bite.

You are a newly minted nurse, you are going to screw up. We all screw up. Take accountability, learn from your mistakes, and take corrective action ASAP when you make a mistake.

litbitblack, ASN, RN · Aug 1, 2008

You can't do it all. You passed it on to the nite nurse who should have called first thing

maolin · Aug 1, 2008

Many times I will leave a postit note for the MD in the MD prog notes - usually an FYI or request for comfort orders, etc - that way you know the doc is informed and don't have to rely on the message being passed down 2 shifts later.

MassED, BSN, RN · Aug 1, 2008

Im a new grad, who got off orientation in May working on med surg. We also just moved our unit and all our patients the other day, so I worked on the new unit that day - it was crazy: no one knew where anything was, and we were all getting a new pt as a transfer from out old unit about Q 45 min-1hr. Most of the time, we'd still be getting report from a nurse on the old unit or had just ended the report when the pt was rolling into the room!
Anyway, I got one pt - woman in her 50s, came in with hypotension and apparently had issues with a fever and diarrhea, although she never had diarrhea on my shift, but did spike a temp which came down with Tylenol. Towards the end of my shift, a family member called and said the pt had had a tick on her not too long before her admission and they forgot to mention it to the MD. I didnt get a chance to page the MD before the end of my shift at 7 - since it was a crazy day, we were all behind and I had also recently got a transfer from a totally different unit (we were told that wouldn't happen ) and had just also found order that were written for that pt around 9am I am guessing and were never mentioned in report not orders taken off and they included 2 units PRBCs!). Anyway, I passed on the tick info in report. (BTW, I did look at the pts skin where she told me the tick had been and there was a small reddened area, but no "bulls eye" rash)
The next day, the nurse that had that pt (also a new grad, I had graduated with her) asked me if I knew anything about a tick (Family had come up and asked her about it) - I told her, yes, I was told and had told the nurse that worked night shift - I guess that nurse never paged the MD, nor passed it on in report.
I really should've paged the MD now and I cant sleep thinking I'll be sued or I caused the pt more harm with delay for possible treatment if she really does have lyme disease!

you passed it on - you didn't have to page a doc for Lyme, that could wait - it was 7pm when you were notified by the family, it appears from your post. It's not an emergency. What I would be more worried about is the PRBC's.... that was the bigger problem.

Vito Andolini · Aug 1, 2008

many times i will leave a postit note for the md in the md prog notes - usually an fyi or request for comfort orders, etc - that way you know the doc is informed and don't have to rely on the message being passed down 2 shifts later.

what if the doctor doesn't read the progress notes or the post it falls off or is taken off? this method is not reliable and you should not rely on it. nothing works like telling the doctor yourself.

and don't expect a night nurse, or really any other nurse, to do your job. a night nurse, especially, is not going to call a doctor unless there is a total emergency. in this case, i'd say she should have called and i wonder why she didn't.

call the doctor yourself. should we be able to rely on the next nurse? yeah, in theory. in today's reality, forget it. the nurse who relieves me can be counted on only to arrive late, dawdle until forced to take report, whine about her personal problems, call the patients bad names, and to do absolutely no follow-through at all. i have learned to tell the docs myself and, yes, i do resent it. but not as much as i fear being sued. we live in an imperfect world.:argue: :jester: :devil:

litbitblack, ASN, RN · Aug 1, 2008

what if the doctor doesn't read the progress notes or the post it falls off or is taken off? this method is not reliable and you should not rely on it. nothing works like telling the doctor yourself.
and don't expect a night nurse, or really any other nurse, to do your job. a night nurse, especially, is not going to call a doctor unless there is a total emergency. in this case, i'd say she should have called and i wonder why she didn't.
call the doctor yourself. should we be able to rely on the next nurse? yeah, in theory. in today's reality, forget it. the nurse who relieves me can be counted on only to arrive late, dawdle until forced to take report, whine about her personal problems, call the patients bad names, and to do absolutely no follow-through at all. i have learned to tell the docs myself and, yes, i do resent it. but not as much as i fear being sued. we live in an imperfect world.:argue:

i don't agree with you here....that is why nursing is 24 hour care. if you can't rely on the nite nurse to take care of what you didn't get to in a reasonable amount of time you mite as well just stay 24 hours a day. if the nite nurse doesn't report it, it needs to be written up. just finding out the info at shift change does not mean you have to stay and wait for the doc to call back, the next nurse can do it.

MassED, BSN, RN · Aug 1, 2008

what if the doctor doesn't read the progress notes or the post it falls off or is taken off? this method is not reliable and you should not rely on it. nothing works like telling the doctor yourself.
and don't expect a night nurse, or really any other nurse, to do your job. a night nurse, especially, is not going to call a doctor unless there is a total emergency. in this case, i'd say she should have called and i wonder why she didn't.
call the doctor yourself. should we be able to rely on the next nurse? yeah, in theory. in today's reality, forget it. the nurse who relieves me can be counted on only to arrive late, dawdle until forced to take report, whine about her personal problems, call the patients bad names, and to do absolutely no follow-through at all. i have learned to tell the docs myself and, yes, i do resent it. but not as much as i fear being sued. we live in an imperfect world.:argue:

vito, that's quite the bad attitude. maybe somebody needs a break from work? job change?

if there's something to relay to the doc that can't wait, then of course you must page the md (and document that the md is paged in case they don't call back). then you can pass it on that you paged the doc, and hopefully the next nurse can continue with the contacting. regardless if it irritates the doc that you called at whatever hour, ask for a lyme titer and maybe start on some antibiotics... as a suggestion (though we know how docs hate being told how to do their job...somebody's gotta do it)..... you can also write a note on their progress notes - i've jotted down notes and taped them to the progress notes, knowing the doc would be in in the am (when i worked on the floor). nothing wrong with that. then when you see the doc, ask him or her if they got the note. no biggie.

if you're worried about no one helping you after your shift has ended, then make the call yourself... don't leave it to the next nurse. sometimes, though, you have to leave that work to the next nurse and you chart "hand off report provided to nurse dave, notified md paged regarding such and such... " if it doesn't get done, well you aren't responsible for other nurses and you can't control everything on that patient.

Vito Andolini · Aug 1, 2008

you passed it on - you didn't have to page a doc for lyme, that could wait - it was 7pm when you were notified by the family, it appears from your post. it's not an emergency. what i would be more worried about is the prbc's.... that was the bigger problem.

i disagree. infectious disease, or a clue to them, must be reported asap, as soon as one is aware of it. how can you possibly justify keeping it from the doctor? how would a jury think? that's what you have to train yourself to do. think like a jury. and no jury is going to sympathize with you for withholding information from a doctor, no matter how low on the list of priorities it was right then. they will think that you should have gotten help from other staff, should have called within a reasonable period of time (like within 1-1.5 hours).

involve your supervisor. get the secretary or phone operator to reach the doctor. drop everything and do it yourself but make sure it gets done. and document what you did to reach the doctor and who else you involved when you weren't able to reach him yourself after 3 tries. call the chief of service or your medical director and notify your unit manager. you must cover yourself. as well as try to help the patient.

if i were the family, i'd have called him myself if i thought i was being ignored but most families aren't like this. they don't know what to do, they don't want to be rude or have us dislike them.

MassED, BSN, RN · Aug 1, 2008

i disagree. infectious disease, or a clue to them, must be reported asap, as soon as one is aware of it. how can you possibly justify keeping it from the doctor? how would a jury think? that's what you have to train yourself to do. think like a jury. and no jury is going to sympathize with you for withholding information from a doctor, no matter how low on the list of priorities it was right then. they will think that you should have gotten help from other staff, should have called within a reasonable period of time (like within 1-1.5 hours).
involve your supervisor. get the secretary or phone operator to reach the doctor. drop everything and do it yourself but make sure it gets done. and document what you did to reach the doctor and who else you involved when you weren't able to reach him yourself after 3 tries. call the chief of service or your medical director and notify your unit manager. you must cover yourself. as well as try to help the patient.
if i were the family, i'd have called him myself if i thought i was being ignored but most families aren't like this. they don't know what to do, they don't want to be rude or have us dislike them.

often times, the doc will consult id regarding suspicion of lyme. according to http://www.journals.uchicago.edu/doi/full/10.1086/508667?cookieset=1

"for prevention of lyme disease after a recognized tick bite, routine use of antimicrobial prophylaxis or serologic testing is not recommended ."

"a single dose of doxycycline may be offered to adult patients (200 mg dose) and to children 8 years of age (4 mg/kg up to a maximum dose of 200 mg) (b-i) when all of the following circumstances exist: (a) the attached tick can be reliably identified as an adult or nymphal i. scapularis tick that is estimated to have been attached for 36 h on the basis of the degree of engorgement of the tick with blood or of certainty about the time of exposure to the tick; (b) prophylaxis can be started within 72 h of the time that the tick was removed; © ecologic information indicates that the local rate of infection of these ticks with b. burgdorferi is 20%; and (d) doxycycline treatment is not contraindicated. the time limit of 72 h is suggested because of the absence of data on the efficacy of chemoprophylaxis for tick bites following tick removal after longer time intervals."

"whether use of antibiotic prophylaxis after a tick bite will reduce the incidence of hga or babesiosis is unknown."

again, not an emergency, it could wait - i believe op noted a person with missed prbc's, that being the higher priority. yes, that would stand up in court.

IamVickiRN · Aug 1, 2008

As a night nurse I am highly offended by that! I always arrive early, I get my report, count narcotics and bid my second shift nurse a fair goodbye. Night nurses DO clean up what others leave behind, not to mention catching the crap from the docs because we have to call them at sucky hours!

racing-mom4, BSN, RN · Aug 1, 2008

Many times I will leave a postit note for the MD in the MD prog notes - usually an FYI or request for comfort orders, etc - that way you know the doc is informed and don't have to rely on the message being passed down 2 shifts later.

I dont leave a post it note as those can fall off or disapear--I just write in the progress notes and date and sign it. If I do talk to the Dr in the night and he gives a new order I will even tell the Dr "I will let you know in the progress notes how well that tx worked"

That way there is a perm record of me stating the problem or offering a suggestion.