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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Rnis, BSN, DNP, APRN, NP
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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.