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?
Stargazer, That was how I was thinking. The room assignment to the med-surg floor had already been made (based on the admission orders) so I didn't believe the dr planned on using the ABGs for deciding disposition--of course, the results could have made him change his mind. But, I looked at the patient and since she was alert and oriented, was able to use bedside commode, had stable vital signs and was not showing signs of DKA or HHNK I felt it safe to treat it as a "stat" admission order, to be done upon admission.
If I had it to do over again, knowing now what my boss expects, I would carry out the order in the ED but I think the way it was presented at the time was somewhat confusing. I think if the admitting dr wants something done in the ED they should convey it verbally or write it as an ED order, not part of the admission orders.
i think we all know the reasons and the precieved importance of the abgs concerning this pt. i would have carried out the abg order while in the er before being transfered, to me it seemed like a very prudent order. live and learn.
what was the stat order? Depends on what it is and if that person can get that in a reasonable period of time - sounds like it was a medical patient, so I'm thinkin' if it was a lab or med that wasn't a truly emergent need, then it could wait... but not knowing what it was that was stat, I'm speculating...
nevermind.... I post before I read all of the other posts so I have my blank slate....
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.
uh, the order was cancelled, so how was this your fault? How long was that order in before it was cancelled? Hours? If it was a long period of time, I would have had it drawn. Our RT's draw our ABG's.... sounds pretty gray, though, so I'd definitely defend yourself on that one. What's up with the threat of termination???? Did the patient decompensate? Did the ER docs not order an ABG initially?
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
not necessarily so... we have residents who continually add admission orders, right up until a patient is wheeled out of the room to their floor. For where I work, medications have to be verified, sometimes tubed from the pharmacy. So if it's ordered 30 minutes prior to departure, I know I'll likely not receive it. The admitting docs may order things stat, but then those will fall on the nurse upstairs. And I'm talking banana bag type orders, not stat Mag, Insulin, Neb, etc.
Stargazer, That was how I was thinking. The room assignment to the med-surg floor had already been made (based on the admission orders) so I didn't believe the dr planned on using the ABGs for deciding disposition--of course, the results could have made him change his mind. But, I looked at the patient and since she was alert and oriented, was able to use bedside commode, had stable vital signs and was not showing signs of DKA or HHNK I felt it safe to treat it as a "stat" admission order, to be done upon admission.
If I had it to do over again, knowing now what my boss expects, I would carry out the order in the ED but I think the way it was presented at the time was somewhat confusing. I think if the admitting dr wants something done in the ED they should convey it verbally or write it as an ED order, not part of the admission orders.
or perhaps page RT for the stat ABG once you saw the order, and if there was time before the pt left the ED, great, if not, their RT can grab that on the floor in a few minutes. I think addressing the ABG was key, in my opinion. If it was another type of stat order, I would take that as it came, depending on what it was... I send patients upstairs all the time when admitting docs order stat meds and they haven't arrived from the pharmacy. I'm not delaying patient care for a stat Lisinopril for a systolic BP of 150. Gimme a break. We have to use our brains and some common sense.
afteralltheseyears
45 Posts
Stargazer, That was how I was thinking. The room assignment to the med-surg floor had already been made (based on the admission orders) so I didn't believe the dr planned on using the ABGs for deciding disposition--of course, the results could have made him change his mind. But, I looked at the patient and since she was alert and oriented, was able to use bedside commode, had stable vital signs and was not showing signs of DKA or HHNK I felt it safe to treat it as a "stat" admission order, to be done upon admission.
If I had it to do over again, knowing now what my boss expects, I would carry out the order in the ED but I think the way it was presented at the time was somewhat confusing. I think if the admitting dr wants something done in the ED they should convey it verbally or write it as an ED order, not part of the admission orders.