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Doctor Denies Giving Lortab Order, Nurse Facing Discipline

What are the consequences with DEA, hospital and my nursing license?

Career Nurse Beth Article   posted
Nurse Beth Nurse Beth, MSN (Columnist)

Specializes in Med Surg, Tele, ICU, Ortho.

Please help me ... what are my choices regarding an order if the doctor refuses to sign this order?

Doctor Denies Giving Lortab Order, Nurse Facing Discipline
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Nurse Beth:

Hi I have a question regarding a situation happened to me recently. I work in PACU as a staff nurse and I do phase I and II. I have only 3 months in this facility. I discharged a patient home after a procedure, this patient is taking at home a Lortab 5/325 mg.

I review the chart and reconcile his medications, as part of the process we can order one dose of the medication that patient is going home, if the patient have a prescription on paper or e-script so I ordered the first dose as telephone order but I don't have to call the MD to get this first dose because is part of the protocol in this facility.

I saw this medication on his reconciled medication and I printed but I did not confirmed that medication was prescribe by other physician than the surgeon that work in this facility. So I order this Lortab under the surgeon name and I gave this pill to patient. I recently received from my clinical supervisor that order was denied by the surgeon and I need to provide more detail about who order this medication because the surgeon refused to sign this order. I emailed back with the same information and I said that order was a verbal order from the same surgeon but he refused this order again.

I really don't know this surgeon very well but I have a conversation just a couple times and he isn't friendly with nurses ( I hope I'm wrong!)
My question is this, what is my choices regarding the order if the refuse to sign this order?
And what is the consequences with DEA, hospital and my nursing license?
Side note: I haven't talk to the surgeon about the order but I anticipate he will refuse this order. Thank you for you time.

Dear Surgeon Refused Order,

So you ordered Lortab 5/325 X 1 po under the surgeon's name and now he is refusing to sign the order, claiming he did not order it.

You say your facility has a protocol that allows you to order one dose of a drug as long as the patient has a prescription for the drug at home, or is it as long as they have a prescription given at discharge (not clear)?

If the patient was given a prescription for 10 Lortab on discharge, and you gave 1 pill, how is the community pharmacy to know 1 pill has been dispensed? Or is it that the pill is not dispensed under the prescription, but the fact that a prescription exists somehow allows a nurse to order the drug independently?

Why not just ask the surgeon for a pain med if the patient needed it before discharge?

That is an unusual protocol.  If there is such a protocol, you must print it out right away and read it carefully because it could save you from discipline at your facility and on your license. If you cannot find anything to print out, then I would say, unfortunately, you do not have a protocol and the protection such a protocol would provide.

Protocol

My questions regarding such a protocol are:

  • What are the criteria for the prescription? All drugs? Controlled substances? Active and current prescriptions? 
  • What is the approved process for ordering the drug?
  • Is it to be entered as a telephone order? If so, under what physician's name?
  • Why would the facility instruct you to enter a telephone order when there was no telephone conversation?
  • Is there an option in your EHR when entering orders to use "per protocol" or "standing order" instead of "telephone order"? If so, that's what should have been used.

This protocol allows the nurse to order a drug based solely on the fact that the patient is on the drug at home, but without consideration for possibly synergistic drugs given as part of the procedure. In other words, drugs should only be ordered as an intervention after a current medical assessment and evaluation.

Such a written protocol would have to include the full process-that the physician will cosign the order within 48 hours when it arrives in their inbox. Nurses cannot order medications independently under any state's BON.

This written protocol would have been approved by your facility's Pharmacy and Therapeutics, Nursing and Medical Executive committees before being posted. If you have such a document like that in your hand, then you are covered and have no worries.

If you are following the facility's protocol as written, and it is a faulty protocol, the liability remains with the facility, not you, and the problem is holding the surgeon to the protocol.

If there is no such document, you are potentially in trouble for practicing medicine, falsifying an order, and drug diversion, very sorry to say.

When following a "protocol" make sure it is indeed a protocol and not just an unofficial nursing practice used for nursing or physician convenience. The term "protocol" is often used loosely and erroneously and puts you, the nurse, at risk unless you are very sure of your facts.

An example is ordering an EKG without a doctor's order if a patient has chest pain. Does it make sense to not delay care? Yes. But many nurses think their facility has a "protocol" for independently ordering EKGs, troponin, and more.

But do they, or is that just what they were told?

Maybe they do, in which case, they need to pull up the policy themselves and confirm exactly what the approved process is. Typically there would be a policy approving specific standing orders to treat the patient which covers the nurse entering an order on behalf of the attending independently.

 Standing orders require co-signature by the attending physian, but can be initiated independently by the nurse if certain criteria are met.

Inconsistency

You entered the order as a telephone order based on your facility's protocol, but when asked about it later, you said it was a verbal order. If it was a verbal order, then yes, the surgeon should have entered it himself, but then the event has nothing to do with a protocol of entering orders without a doctor's order based on a prescription discovered during medication reconciliation.

Unless I'm misunderstanding, your account of what happened is inconsistent and confusing. I know this is probably catastrophic to you now, and your thoughts may not be clear, but inconsistency will be used against you.

Was it a telephone order based on protocol or was it a verbal order? Did you ever see the surgeon or talk to him?

Verbal Orders

Do not take verbal orders except in the case of an emergency, or when it would break a sterile field to do so. Verbal orders, as well as telephone orders, can become a "he said, she said".

If you asked the surgeon for pain medication for your patient and he responded verbally to give Lortab 5/325 po X 1, the proper response is "Thank you, will you be entering that as an order?"

You are not in trouble with the DEA but you are in trouble with your facility. You are not in trouble with the BON at this point, but if your facility chooses to report this to the Board, you could well be under investigation. If your facility reports you to the BON, you may not hear anything from the Board for some time, depending on their backlog of cases and next scheduled meetings. If you do hear from the Board, get a lawyer, and get one that has experience representing nurses to the Board.

I am so sorry that you are going through this. You made some risky choices.

You must be very careful about protecting your nursing license and think things through. It is just not worth it to jeopardize your career and your future.

Best wishes,

Nurse Beth

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I work in an FQHC and we refill 30 days worth of medications all the time. Non-controlled substances, and only those for chronic medical conditions. The nurses have repeatedly asked for a written policy on this— one of the nurses wrote one and hand carried it to our compliance department— but are told things like “We only review policies once every calendar year” and “We will look at it and get back to you.”  We are a small staff, and none of the nurses, including me, has the time to make this a huge battle. The providers are under the impression that this protocol is written down somewhere. They say things like “Go ahead and refill that, per protocol.”  But it isn’t written  anywhere. What should we do about this?

TriciaJ, RN

Specializes in Psych, Corrections, Med-Surg, Ambulatory.

Sounds to me like a med error,  based on a misunderstanding of the protocol.

Review the protocol and figure out what you missed.  Sounds to me like it's a dicey protocol that needs to be reviewed.  Any protocol is only as good as the doctors are willing to back it.

As far as DEA, BON, etc. it would have to be a slow week to get in an uproar over one pill.

This should be a live-and-learn, not a career killer.  Take a breath.

Numenor, BSN, MSN, NP

Specializes in Internal Medicine.

Inconsistent story, but as the provider I would usually do the nurse a solid and back them up on this. 1 Hydrocodone isn't going to rustle my jimmies. This protocol is is rife for issues though.

beachbabe86

Specializes in Oceanfront Living.

3 hours ago, CommunityRNBSN said:

I work in an FQHC and we refill 30 days worth of medications all the time. Non-controlled substances, and only those for chronic medical conditions. The nurses have repeatedly asked for a written policy on this— one of the nurses wrote one and hand carried it to our compliance department— but are told things like “We only review policies once every calendar year” and “We will look at it and get back to you.”  We are a small staff, and none of the nurses, including me, has the time to make this a huge battle. The providers are under the impression that this protocol is written down somewhere. They say things like “Go ahead and refill that, per protocol.”  But it isn’t written  anywhere. What should we do about this?

as a former health care surveyor, BON staff, and years of staff nursing, these comments make my stomach turn. 

Nurses should absolutely stand up for written policies and procedures.  Otherwise, nurses don't have a leg to stand on.  And if you think the docs will back you up, you are very much mistaken.

I don't understand. If it's the protocol, wouldn't there be preprinted orders? And if it's per protocol why say verbal order unless you spoke to the doctor? Also, you say it's protocol under the physician during med reconciliation but you sen the order under the surgeon, whom you didn't speak to. If that's the case, the error is your fault as the order should have been sent under the reconciling physician and not the surgeon. That would still present a problem because the physician should have been the one consulted for post-op pain medication.

I don't think it will be a career ender, but you need to seek clarification and written rules regarding the protocol. In the future, call a physician so they can send the order, doesn't matter if it falls under protocol or not. Take this as a learning experience and never repeat it again.

11 hours ago, NurseBlaq said:

I don't understand. If it's the protocol, wouldn't there be preprinted orders? And if it's per protocol why say verbal order unless you spoke to the doctor? Also, you say it's protocol under the physician during med reconciliation but you sen the order under the surgeon, whom you didn't speak to. If that's the case, the error is your fault as the order should have been sent under the reconciling physician and not the surgeon. That would still present a problem because the physician should have been the one consulted for post-op pain medication.

I don't think it will be a career ender, but you need to seek clarification and written rules regarding the protocol. In the future, call a physician so they can send the order, doesn't matter if it falls under protocol or not. Take this as a learning experience and never repeat it again.

Meant to say the surgeon should have been the one consulted for post-op pain medication.

On 7/2/2020 at 4:17 PM, CommunityRNBSN said:

I work in an FQHC and we refill 30 days worth of medications all the time. Non-controlled substances, and only those for chronic medical conditions. The nurses have repeatedly asked for a written policy on this— one of the nurses wrote one and hand carried it to our compliance department— but are told things like “We only review policies once every calendar year” and “We will look at it and get back to you.”  We are a small staff, and none of the nurses, including me, has the time to make this a huge battle. The providers are under the impression that this protocol is written down somewhere. They say things like “Go ahead and refill that, per protocol.”  But it isn’t written  anywhere. What should we do about this?

You had better make the time.  What do you mean you don't have the time?????  You just want someone else to fight the battle for you.  

Have you got a union?

Time to get those providers on your side by getting their signatures on a statement to the Board of Directors, the hospital Prez, the DON, and every other bigwig who apparently knows nothing and cares less about the problem such ridiculousness creates for you nurses.

Sounds like it's time for a strike.  They can just move up that yearly meeting to RIGHT NOW.  

They won't, though, unless ALL of you - not just you by your lonesome - march to the office of the CEO/Pres and make him/her understand how your fannies are hanging out there in the wind.

Of course, if you are actually speaking to the docs, why not put the chart in front of them and have them pick up a pen and write the orders, if there is a hard chart any more anywhere.  If you can get them to enter it by computer, even better, I suppose.  Stand over them until it's actually entered.

TriciaJ, RN

Specializes in Psych, Corrections, Med-Surg, Ambulatory.

On 7/2/2020 at 2:17 PM, CommunityRNBSN said:

 The providers are under the impression that this protocol is written down somewhere. They say things like “Go ahead and refill that, per protocol.”  But it isn’t written  anywhere. What should we do about this?

"I'm sorry, Doctor.  There isn't actually a protocol.  We're working on it, but in the meantime will you please write an order?"

This covers everyone's butt in the event there is a discrepancy and it is discovered that there is no protocol.  The doctors should cheerfully write you an order, or they can get themselves in an uproar and raise hell with management.

I am so sorry you are going through this. You need to protect your license because you worked hard for it. Like Nurse Beth said, is this the protocol or its surgeons too lazy to do their so the nurses risk their licence instead of dealing with him/her. Just because he is not friendly is not licence to do things beyond your scope of duty. Call and get clarifications, even if it takes longer or  not so pleasant surgeon. Nurse Beth said it all, very comprehensive answer. Your account of events is not so clear and very ambiguous. Good Luck?

Dr Madenya

It sounds like discharge med orders the doctor should have handled. There should be a form that you have as your evidence as to what is a standing order and what isn't. I will repeat orders back to doctors and question them to.  Sometimes I get, o know, I meant this. This comes from my experience of working at a teaching hospital (dealt with baby doctors who made errors).

WOW!  no nurse can trust this Dr , that is standard procedure. every nurse should refuse to take any oral order from this Dr.

Sounds like something else going on !

3 hours ago, kuippo said:

WOW!!  no nurse can trust this Dr , that is standard procedure. every nurse should refuse to take any oral order from this Dr.

Sounds like something else going on !

That isn't really a "verbal order".   He did not give an order,  she ordered under what she thought was a protocol.    I honestly doubt there is a true protocol order in place for narcotics, because this is so regulated now.   I probably would haves (and have done this once  ) by co-signing a narcotic that a nurse ordered through an inappropriate protocol....but it would have bothered me and I might say something to clarify expectations for the future.   I wouldn't co-sign it a 2nd time though.

Might be worth having a conversation with the doc and explaining your interpretation of the policy and explaining your actions. The doc may very well sign off the order and say don't do it again. Sometimes a clear line of communication makes things go much easier. 

There was no verbal order and no telephone order involved here. If it was ordered as either one of these, that was incorrect. This is not about a physician not backing up an order s/he gave. Period.

I can't imagine any provider would really like to have a bunch of nurses collectively entering innumerable "verbal" orders when there were  no conversations and no verbal orders given.

*If* there's a protocol, there should be a means by which to indicate this when entering the order. Protocol orders should be denoted as such, and they are supported by a protocol which comes into being via agreements as described by Nurse Beth (pharmacy, medical, nursing executive committees).

On 7/2/2020 at 10:21 AM, Nurse Beth said:

I ordered the first dose as telephone order but I don't have to call the MD to get this first dose because is part of the protocol in this facility.

That isn't right. It was not a telephone order.

On 7/2/2020 at 10:21 AM, Nurse Beth said:

I emailed back with the same information and I said that order was a verbal order from the same surgeon but he refused this order again.

This was not true. It was not a verbal order.

The member who submitted this question needs to investigate the existence of the protocol and review it ASAP. If there is no actual protocol in writing then your only safe option is to actually obtain telephone orders when you need orders and/or to have the physician enter his/her own orders for extra items they want the patient to have.

Sounds like you really need to review the protocol in detail and become more familiar with it.  And, seek clarification especially when it comes to dealing with narcs.  Saying it was a verbal order when you didn’t actually receive one is irresponsible and error on your part.  Part of being a nurse means unfortunately dealing with some difficult, not so nice doctors but that should never stand in the way of protecting yourself, your license, and of course the patient.  So make the call to clarify when in doubt no matter how silly it might sound.  What’s the worst they can do to you?  And who do you think the board or law will side with if they see you were just doing due diligence to clarify in order to be safe?   They get paid probably triple what you do...make them do their job.  If you don’t, then you’ll find yourself in situations like this. 

Your supervisor/DON should know the answer on the ramifications and give you guidance if the surgeon doesn’t sign it.  For med errors/sentinel events in my facility, typically we would have to file a report.  A clinical staff reviews it and determines the seriousness and if any disciplinary action should be taken.  It is more as a teachable moment rather than just trying to penalize staff unless they were clearly and extremely negligent.  It also helps identify and fix errors or inconsistencies in protocols/policies which could lead others to make similar mistakes.

This error doesn’t necessarily mean your going to lose your license...that might be jumping the gun.  But you should ensure it doesn’t happen again.   In the meantime, sounds like you should direct this question towards your supervisor/leadership for a more accurate answer as to what could happen and guidance on how to handle this.

On 7/9/2020 at 9:06 AM, MInurse2b said:

Part of being a nurse means unfortunately dealing with some difficult, not so nice doctors but that should never stand in the way of protecting yourself, your license, and of course the patient.

This is true, but...

On 7/9/2020 at 9:06 AM, MInurse2b said:

In the meantime, sounds like you should direct this question towards your supervisor/leadership for a more accurate answer as to what could happen and guidance on how to handle this.

I put administrators into the same category of people whose advice and "protocols" on things like this are always to be double-checked and verified. I'm not sure what the case is in the scenario we're discussing but it wouldn't be the first time that an employer directed nursing to do something a certain way knowing that if there were any fall-out it would be doctor vs. nurse and the wrong could be pinned on one or the other. They have a habit of being oblivious to the interests of other parties.

Part of being a nurse is reasonably vetting information no matter the source.

If someone says there's a protocol for something, you say, "great, where is that so I can take a look at it." Then you make sure it makes sense and isn't nonsense like "the RN may do [xyz] by entering a verbal/telephone order..."

On 7/9/2020 at 10:45 AM, JKL33 said:

This is true, but...

I put administrators into the same category of people whose advice and "protocols" on things like this are always to be double-checked and verified. I'm not sure what the case is in the scenario we're discussing but it wouldn't be the first time that an employer directed nursing to do something a certain way knowing that if there were any fall-out it would be doctor vs. nurse and the wrong could be pinned on one or the other. They have a habit of being oblivious to the interests of other parties.

Part of being a nurse is reasonably vetting information no matter the source.

If someone says there's a protocol for something, you say, "great, where is that so I can take a look at it." Then you make sure it makes sense and isn't nonsense like "the RN may do [xyz] by entering a verbal/telephone order..."

I agree, we definitely need to double check behind administrators also.  Clearly something is either wrong with the protocol in place or the nurse misinterpreted it.  But either way, I think the administrators should still be able to tell this person what the ramifications will be if the surgeon doesn’t sign the order.  They are actually responsible to follow up and determine what needs to happen in a situation like this.

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