Failing to carry out a stat order in timely manner

[afteralltheseyears]

I made a mistake in deciding to send an admitted patient to the medical floor (from the ED) and have a stat admission order carried out there rather than seeing that it was done in the ED prior to admission. The patient's condition was not such that I believed the delay would harm them and in fact, the consulting specialist came along before the stat order was carried out and cancelled it stating it was not needed.

I know it was the wrong thing to do (stat means it should be done without delay) but felt it was for a good reason (so the rest of the patient's admission orders would begun to be carried out sooner to the benefit of the patient). If I had it to do over again I would have kept the patient in the ED longer so the stat order could be carried out but it's too late now.

My manager has expressed he has a problem with my not planning to carry out the "stat" order and I'm afraid I'll be terminated for it. If you were a manager, would you terminate a nurse who did this?

[nurse2033, MSN, RN]

It's impossible to know all the issues at the front of a manager's mind. If you went out of protocol, you are at risk. If you had good reason, that was in favor of the patient, you should present this reasoning at any meetings if needed. You seem to be validated by the specialist. If your manager is good, they will understand that you understood the clinical picture, if they suck they may look only at the protocol issue. You are best positioned to judge the political climate. It is hard for management to fire someone if they state "I realize my mistake, I'll make sure it won't happen again" versus any other kind of defensive rationalization (unless they are decided to fire you anyway). If you value your job, jump through hoops if needed. We are trained to make decisions and you made one that you felt was correct, but that is not always valued by management, who have their own issues and agendas. Regardless of protocol, I think you know if you did the right thing or not. People who do the right thing are moral and ethical, and those who blindly follow protocol are sheep. Unless you can't stand to work there, keeping your job is your priority for you own benefit. Best of luck!

[MesaRN]

We are paid to use our nursing judgment and to be patient advocates. According to your post you were using your best judgment in order to obtain the best outcome for the patient. In retrospect the best way to have handle the situation would be to communicate with the EDP (or admitting doc) about wanting to get the pt to the floor before carrying out the order. I have found more often than not the docs are very open and receptive to these idea as they are the experts in pt care but not necessarily in hospital flow.

Under this specific situation and without further details of the order it sounds very unlikely that it would be a terminable offense. An ER nurse faces situations like this on a daily basis. Communication with the ordering physician, an EDP or other doc, can greatly reduce these conflicts.

These types of situations can result in sleepless nights. Talk with your manager ASAP for your own benefit. Usually we make a situation worse in our minds than it is in reality.

[GHGoonette, BSN, RN]

I've never been in this kind of situation; stat is stat, unless the doctor states specifically that the order can be carried over to the ward. As previously stated, it's always a good idea to consult with the doctor if you think it's in the patient's best interests not to give the med immediately.

You were borne out by the specialist's decision, and the patient took no harm, so I can't see any reason for dismissal; I would suggest that the manager's course of action, if this is the first time this has happened, should be counseling and/or verbal warning. Take it as part of the learning curve and be warned.

[afteralltheseyears]

I appreciate the responses. The suggestion to contact the admitting resident to clarify what should be done where would have been a good thing to do. I am an experienced RN (28 years), just attained my CEN for the second time--I feel I know my stuff but have just worked at this location for a year and have never felt I fit in (the political aspect) Anyway, here was the situation:

patient was elderly, came to hospital in CHF/mild pulmonary edema (4+ edema and wet sounding lungs). Received nebulizer and lasix by EMS and received more upon arrival to ER. Breathing became less labored and patient began to diurese slowly. She has history of chronic kidney disease and Type 2 DM-both of which were born out by labs (had high BUN/Creat and blood sugar of 796). Patient takes insulin and had taken hers that am (this was afternoon). Patient was alert and oriented, alittle hypertensive, only had mild tachycardia (after breathing became less labored) and had no kussmaul resps or fruity breath. The ER Dr did not order insulin. She treated the chf/pulm edema and then called in the medical school family practice clinic resident on call. After evaluating and writing admission orders for the patient over a 2-3 hour period of time, the resident's orders appeared he was planning to address the hyperglycemia. I wasn't alarmed by the fact that no insulin had been ordered so far because normally insulin for a very high blood sugar follows receipt of IV fluids and potassium which needed to be approached carefully in this patient considering her history. The patient remained hemodynamically and neurologically stable during ER stay after her initial respiratory distress was controlled. The Stat order that I didn't plan to carry out in ER was for ABGs. I realize it was to see if she was acidotic but felt because the patient's condition was stable and the "stat" order had probably been written at least an hour before I'd received it they could be drawn upstairs along with initiation of other orders (first order for IV fluids, more labs and consulation with nephrologist) that would eventually lead to orders for insulin. As it turns out the nephrologist came in before the patient was taken upstairs and cancelled the order for ABGs.

So, what do you think now? My manager thought I might have entered the gray area of diagnosing/interpreting too much.

[HiHoCherry-O]

I would have carried out the order. How long of a time frame was it from the time the order was written to the time it was canceled? An ABG can tell you many things. This patient had multiple problems going on, all of which can affect ABGs (high glucose level, CHF etc). The result may or may not have changed the admit destination for this patient. It may have alerted the doctor to keep an eye on another potential problem emerging during the patients hospitalization. It would also be a good baseline to reference should the patients condition change.

I am sorry, but I do not buy that by not carrying out the order, this is facilitating the other orders to be started. An ABG takes. . .10 minutes?? Do you have RT's in the ED? Do you as a nurse draw the ABG? RT's draw the blood gasses in my department and have a blood gas analyzer right there in the department. Even so, when drawing a co-ox off a swan (which the RNs do), the results come back from lab in about 10 minutes.

Should this order have not been canceled, I predict the patient would have gone to the floor, the receiving nurse would now have to address this issue, arrange for it to happen, amidst the whole addmission process that we all know takes a long time (paperwork, paperwork), still keep up on the other patients she/he has as well as verify all the other orders that need to be done.

As a manager, I would expect more out of you with your 28 years of experience, however, I would not terminate you.

Just my .02 cents.

[afteralltheseyears]

I appreciate your input HiHoCherry-O

It was alittle over 30 minutes between the time the order was received and the specialist came in and cancelled it. I hadn't thought of the time it might take for it to be carried out on the floor. It would probably take 15 minutes until results in ED. I should have carried out the order--hopefully my manager will give me a chance to show I learn my lesson. Thanks.

[Been there,done that, ASN, RN]

Any order placed in ER, should be executed in ER. After the patient is transferred, it will delay the the doctors request, by hours.

When I am working on the floor, I would see that as a turf of responsibility to me,, would take me awhile to process orders, note what still needs to be done.

Whatever the order entailed is not the issue. It was a stat, pure and simple.

This is a patient safety issue. As you seem to have learned from your mistake, I would be hopeful that your manager realizes this, it is all we can do in this most difficult profession, learn from our mistakes

Best of luck to you.:redbeathe

[mmutk, BSN, RN, EMT-I]

Please clarify for me, was the order on the ER order sheet or on the admission orders. And what was the order itself and the patient's diagnosis. There is more information I would need to give you an answer to your question.

[afteralltheseyears]

The orders were written by the admitting Dr (not the ED Dr) and were admission orders.....so my interpretation was that because the patient was relatively stable the orders could (and even should) be carried out when the patient was admitted.

I've not gotten terminated and have communicated with my manager that I now know admission orders (at times) should be initiated by the ED nurse. Still alittle fuzzy and subjective if you ask me.

Thank you

[steelydanfan]

No, no and again no! The admitting and the house docs REALLY needed those ABGS to know the trend and scope of this patients disease.

If you have a problem with a doctor's orders, you CANNOT just ignore them, or put them off: just call the doctor with all of your courage of convictions.

[Anna Flaxis, BSN, RN]

If the order was part of the admitting orders, written by the admitting physician, then the order was to be carried out on admission to the floor. If you had time to do it in the ED before sending, that would have been nice of you, but not required, in my opinion.