MD refuses to sign a telephone order.

[modernhippie_]

I'm a new grad working on my own for almost a month now, starting in ICU at a hospital where the acuity of the patients is rather low, so I consider it a SICU. I had a pt with a history of cvs with right sided weakness. She was obese and refused her scd stockings. I knew this woman was a huge risk for clots, so I educated her and charted the education and her refusal. To cover my butt, I called her attending md to let her know, and asked if sag wanted to try an alternative DVT prophylaxis. She stated ..this pt was on a Helprin protocol right? I said yes but it was stopped. She said ok give her 30mg lovenox sq daily. I wrote it down on the chart and got the med from pharmacy. Gave teaching to pt on lovenox and administered med. I documented a MD notified for the refusal and that new orders were received. I get a call a week and a half later from my unit manager saying that the dr refused to sign the order because the pt has HIT. They sent a HIT test out during the shift prior to minr, but I hadn't seen the results and not sure if they were even back yet. The unit manager asked if I was sure it was tht dr I spoke to. I said yes, and in the chance that it wasn't, it had to be someone who was covering for that dr since they were clearly aware of who the pt was, even stating to they knew she was previously on a Heprin protocol. The mgr told me I need to be sure, and asked if I'm trying to say the dr was lyng? I was shocked!! I told her to check the phone records and see if that particular MD called on the date and time tht I charted her telephone order. She said she can check to see who was on call tht day. I JUST got my license a few months ago, and I'm shaking at the thought of loosing it over a matter of her word against mine. When r they going to start recording every phone call so ths doesn't happen. I am so angry and I wanted to know what I could do to prevent this from happening again, if anything.

[modernhippie_, BSN, RN]

Thank u everyone for your feedback. I will need to stick to sbar better and do my he more before calling the dr. I hope this comes easier with experience. Also I liked how a lot of u suggested getting another nurse to verify the order so I have backup, at least with this particular dr.

[EMSnut45, BSN, RN, EMT-P]

I do not know what it is, a test? a diagnosis?

HIT= Heparin Induced Thrombocytopenia

If HIT is suspected, a blood sample can be sent to lab to confirm or rule it out.

OP-- A pending HIT test should be passed on in report. If not, you should have seen the order as you reviewed the chart with the off going nurse, or during your 12 hour chart check (something I always do at the very beginning of my shift).

As a critical care nurse, you need to know your patients lab values too. This is something else I check at the very beginning of my shift, right after report. If I have two patients, I can do this in less than 15 minutes. If I have an inevitable emergency at change of shift, this is something I make a priority to do once everything settles down again. I consider it a part of how I keep a patient safe (what if the physician missed the K+ of 2.5 and by you looking, you can alert them?).

Also, a + HIT should be a critical value that the lab should call and verbally report to the nurse as well. Does your hospital do that?

It's hard to be new in the ICU! Hang in there!!

[TopazLover, BSN, RN]

Thanks, every once in a while the abbreviations don't click.

[iluvivt, BSN, RN]

Totally agree with cstrazis! We also post a sign above the bed or on the ICU glass door that a HIT lab test is pending . This serves as an extra alert so no one decides to order any heparin and all heparin flushes are held until results have been obtained. One thing too that may have tipped you off to a lab test pending or a problem is to check the patient's platelet count. The MD probably saw it decreasing and ordered the lab test.Also immediately list heparin as an allergy if the test comes back positive.

Now as far as the MD goes I suspect they were not aware of the test result pending either and now cannot take ownership of the order. I am of course not certain of this but I would have a high degree of suspicion. This is a great example of how critical the nurse really is because if you would have been able to piece the puzzle together you probably would not even have called the MD.

On high alert mediciations I too would get a second nurse on the line if a telephone order must be taken.

[sapphire18]

Even if you didn't know about the HIT test, always check platelet counts before giving lovenox.

[IndiCRNA]

Ya this has happend to me a number of times. However I have never viewed it as MY problem. It's managment's (nursing and physician) problem. Obviously you wrote the order as "T.O Dr.Liesaboutorders". The last time my nurse manager called me about an unsigned order and asked me if I was sure about the order I had recieved. I said "yes, now good luck with that, bye bye".

One hospital I worked at we had a doc who would refuse to sign tephone orders occasionaly. After this happend to several nurses we all got together and agreed that none of us would accept phone orders from him again. That meansd he had to come in so many times that he ended up just sleeping in the hospital when he was on call. This made his life so miserable that he quit. Man was he mad! He used to threaten us with being fired (our NM laughed at him) and all sorts of other things.

You need to remember this particular physician is a person with low integrity and NEVER take another phone order from her again.

[Seasoned]

"I told her to check the phone records and see if that particular MD called on the date and time tht I charted her telephone order. She said she can check to see who was on call tht day. I JUST got my license a few months ago, and I'm shaking at the thought of loosing it over a matter of her word against mine. When r they going to start recording every phone call so ths doesn't happen. I am so angry and I wanted to know what I could do to prevent this from happening again, if anything."

It has happened to all nurses at least once. But to smart nurses only once!

:yes:It is really important that you have CYA game plans to protect your license. So it is very good you are reaching out to collect suggestions! For MD orders at places that do not have electronic records your back-up is your colleague, charge nurse, or nurse supervisor as a witness. For every MD verbal order? YES!

The practice of verbal orders are outdated, keeping nurses at the mercy of physician negative politics. Only the progressive electronic record systems will save a nurse from a verbal order dispute.

Get in the habit to TELL ANOTHER NURSE for every verbal order and put her name in your progress note, e.g., "In consultation with Betty W. RN.... or I mentioned my suggestion of_______to Nurse BW who witnessed my getting a verbal order from Dr. Con at 2300." Word it anyway you iike. Just write the narrative ASAP after documenting the exact time with your witness that the order was said.

[riggy3, MSN, RN]

The use of phone orders is one with many errors. Be sure to document the readback of the order to the physician and they confirm. Very soon all orders will be electronic and the responsible doctor will be typing what they want leaving no room for the denial who wrote what.

[IndiCRNA]

"I told her to check the phone records and see if that particular MD called on the date and time tht I charted her telephone order. She said she can check to see who was on call tht day. I JUST got my license a few months ago, and I'm shaking at the thought of loosing it over a matter of her word against mine. When r they going to start recording every phone call so ths doesn't happen. I am so angry and I wanted to know what I could do to prevent this from happening again, if anything."

It has happened to all nurses at least once. But to smart nurses only once!

:yes:It is really important that you have CYA game plans to protect your license. So it is very good you are reaching out to collect suggestions! For MD orders at places that do not have electronic records your back-up is your colleague, charge nurse, or nurse supervisor as a witness. For every MD verbal order? YES!

The practice of verbal orders are outdated, keeping nurses at the mercy of physician negative politics. Only the progressive electronic record systems will save a nurse from a verbal order dispute.

Get in the habit to TELL ANOTHER NURSE for every verbal order and put her name in your progress note, e.g., "In consultation with Betty W. RN.... or I mentioned my suggestion of_______to Nurse BW who witnessed my getting a verbal order from Dr. Con at 2300." Word it anyway you iike. Just write the narrative ASAP after documenting the exact time with your witness that the order was said.

When I was a ICU and ER staff nurse I had to take verbal and phone orders all the time. A number of times a physician denied giving an order. It was never a problem for me. I never experienced anyone doubting that the order had been given if I said it had been. Usually just ask "Indi are you positive the doc ordered xyz?" I would say "yes I am sure" and that was the end of it from my point of view. It was alwasy assumed the order had been given and the problem was with the physician and something to be dealt with by her boss.

If a doc gives you a phone or verbal order and then denies it and your nursing managment doubts your word then I would find a new place to work. I wouldn't work for any organization that doubted my professional integrity. Like I said never been a problem for me and were I still a staff nurse I would take those orders (if the situation required it) without a second thought.

[jalyc RN]

That is similar to my experience when I was a new nurse in 1973.

I worked L&D at a BIG county hospital. LPN's were not supposed to give IV pushes, but we commonly did IV Pitocin in delivery rooms for the doctors who were scrubbed and working. They would then sign the MAR BEFORE leaving the room. One doctor refused to sign for me. My head nurse told me not to give anymore for him; to call an RN back as needed.

Next delivery was a bleeder and all the RN's were tied up in other deliveries and C-Sections so he had to break scrub to give the Pit. He was furious and complained all the way to the Chief of Staff, wanting me fired for my 'refusal to follow orders'. lol

My HN explained what had happened and instead of me being fired, L&D was designated a "Critical Care Unit" and LPN's with proper training were then allowed to give IV pushes legally.

OP, one HN always told us, "If you come to me with a problem, bring a solution with it too." Advocate for changes that will help both you and your patient.

[Ruby Vee, BSN]

First off, why would you call a low acuity ICU a SICU, which in my mind stands for surgical intensive care unit?

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Yes, I thought that was pretty insulting as well. And the OP's scramble to say she meant "MICU" instead wasn't very flattering, either. A low acutity ICU is a low acuity ICU. MICUs can be pretty high acuity. But anyplace that has a MICU probably has another ICU as well . . . usually a SICU. Hospitals with more than one ICU are likely to have higher acuity patients than a small hospital that has just one ICU.

[Ruby Vee, BSN]

OK, no. None of you work with the OP. So cut the crap about the acuity of her workplace, PLEASE. Sheesh.

Nope, none of us work with the OP, but the OP is the one who started the crap about the acuity of her workplace. Some of us found it insulting that the OP said she called her workplace a SICU because it was low acuity. Then some of us found it insulting when she said oh, no, she meant MICU. Perhaps the OP should apologize for denigrating SICUs and MICUs.