Ever Refuse a MD order?

Nurses General Nursing

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Just wondering if anyone has ever had to refuse a MD order??

I alwyas feel orders are more suggestions. We are the gatekeepers to ensure harm does not reach the patient. Some order are held or not done because it is not appropriate at the time. A nurse should never blindly follow or we should all be replaced by unskilled labor.

When you have slew of residents running around you have to help them out sometimes. They write for some inappropriate things and most understand that we all are working on the same team, but there are ones that develop the early ego syndrome and that is when their senior, fellow or attending can be helpful to ensure patient safety.

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Yes, but not for fun, for survival. It was definitely license threatening.

I can't go into the details, but here are the generalities:

1. When your license is threatened by an order, choose the nuclear option, unless you don't care if your family eats.

2. When you choose the nuclear option, don't mess around and don't hold back.

3. Tell everyone, and tell everyone else who you told, not just to keep everyone in the loop, which is wise, but because knowledge creates a duty to act when others know the knower knows.

4. Do the research before you say a word. You might be dead wrong or gloriously right.

5. Don't do squat if you think you'll chicken out or lose. You want an unassailable position, because you're betting the bank.

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4. Do the research before you say a word. You might be dead wrong or gloriously right.

5. Don't do squat if you think you'll chicken out or lose. You want an unassailable position, because you're betting the bank.

The standard to meet is if the situation is obvious to the layman which is the basis for the Prudent Nurse Standard. Otherwise it becomes an issue of Medical Opinion which is a losing proposition for a nurse.

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Specializes in Psych ICU, addictions.

One doc wasn't paying attention to his patient's vitals and ordered lopressor for an increased pulse. The patient's pulse was up...but her blood pressure was in the mid-70s. When he said what he was ordering, both the medication nurse and I screamed "NO!" at him. That got his attention fast and he cancelled the order :)

And the doctor took our reaction rather well, considering he's known for having an attitude problem. Never had any problems with him.

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Specializes in LTC Family Practice.

Yup, I used to work with residents (little docs) in a FP outpatient clinic and one wanted to insert an IUD in a pt with chronic PID:eek::uhoh3: because she didn't want to take pills (non-compliance/lazy issues) I told him noooo not gonna happen and of course he's trying to pull the "I'm the doctor" BS and was acutually stomping his feet (I tried so hard not to laugh:rotfl:) so I went and got the Dept Head Doc and told him what Dr. "can't read the chart" wanted to do and Dept Head backed me up big time:D.

As another poster said we are the gatekeepers and when I worked with the residents it was a must and Dept Head Doc backed us all the way, so there was never any repercussions.

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Specializes in PACU, ED.

We do serve as a second check or sanity check for orders. I had an anesthesiologist give me orders for morphine for pain for a pyloromyotomy pt. I asked for tylenol orders instead and explained why narcotics were not a good idea. Another time a PA ordered IV fluids of D51/2NS+20KCl at 107cc/hr on a 12 yr old who'd just had a dialysis cath inserted for kidney failure. The surgeon happened by before I had a chance to page and agreed with my suggestion of NS at KVO.

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I had a fresh post-op in the SICU - some belly surgery. Anyway, the Anes. giving report stated the patient would need something for pain, but he was having a hard time deciding exactly what he should order.

In the end he told me, "just give him whatever any prudent nurse would give for pain and I will sign off on it." To date my favorite order! How did he know if I was a prudent nurse?

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Ok I have a question. I'm only a student so please don't yell at me, but what do ya'll mean when you say prudent nurse?

Thanks

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Prudent nurse means a nurse with good judgment who follows typical standards of care.

I had a resident order 5mg Ativan in an elderly pt who was having mild insomnia. I said, are you sure? Do you mean 0.5mg? She acted really annoyed and said no. I kept questioning her and finally she called back. I asked if she meant Ambien, not Ativan, and she ordered 2mg Ativan. I gave 0.5mg and the guy slept and snored all night. She didn't last too long though.

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I worked years ago on a med-surg unit in a VA hospital for several months (before transferring to psych, which was my specialty and what they actually hired me for). There were several times that one or another of us went to our NM with questionable med orders written by one resident or another, and she would approach the resident and inform her/him that no nurse on the unit was going to give that medication to that client, and, if s/he really wanted the client to have that medication, s/he would have to administer it her/himself. It was amazing how often the resident changed her/his mind when it was going to be her/his thumb on the plunger of the syringe ...

(jenmarie -- "prudent" is a term used in legal issues in nursing (and other professions); "prudent nurse" means a safe, competent, cautious, responsible nurse (as opposed to someone who would just do any crazy thing a physician told you to :)).

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Specializes in ER/EHR Trainer.

All the time....in a teaching hospital you'd better be one step ahead of the residents and the personal physicians that come to treat their patients.

Never treat on a K+ on an istat-make sure it isn't hemolyzed-I wait for real labs after asking for a stat run-almost always the speciman was wrong.

Always run drips and meds on parameters and facility policy...doctors love to order meds without these clarified...the patient won't get it if it's not ordered correctly...also lets the doc know what you know and they will respect you for it.

Won't discharge from the ER until vitals normal and patient stable-personally, I can't understand keeping the drunk to sleep it off, yet trying to discharge the bp with a systolic>100-isn't going to happen with me.

Overall, any order is questionable if contraindicated due to the patient's vitals, abilities, and current condition. That's why nursing is so hard, and that's what drives me crazy with nursing's perception by the general public. They really don't get how we protect them.

Maisy

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Specializes in ER, Step-Down.

yep - just the other day I was going to use "nursing judgement" on an order. Resident ordered 60mg toradol, IV. Called the doc up, wanted to know if she wanted 60 *IM* or *30* IV. She said she "looked it up" and that 60 IV wouldn't hurt the veins! Uhhhh... I'm not overly concerned about that. I adequately flush and dilute with saline... but what about the kidneys??? Next thing I know, 5 minutes after she insisted it was 60mg IV, the order was changed to 30mg IV. :) Of course, this is the same resident who wanted to d/c a pt who came in with a foot fx, after nursing staff found several empty pill bottles of benzos that had only been filled a week prior. We fought it, went to the attending, shortly after my shift ended the pt went into status and had to be tubed.

then there was the time we had a floating IM resident in our ED and the one attending actually told us nurses to check and double check all the orders she wrote and to come to him immediately if we thought anything was off... oi vey. *rolls eyes*

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