I am an ER nurse. I came on shift and received report on an elderly pt. with dementia. There was an order for 2.5mg haldol IM. I was told by the provider not to give the pt. the haldol because she had a history of "going downhill fast" and that the pt.'s husband was on the way to pick her up anyway. While I was in another pt.'s room and without asking me, a coworker of mine gave the pt. 5mg of haldol IM and didn't document it. I only found out after finding the empty vial and finding 2 other staff members who admitted that they witnessed it. The pt's husband showed up to take her home. Should I have said anything?
Heres what I did... I asked the nurse who gave the injection to let the provider know it was given, to let her know that twice the ordered dose was given, and to document it. She got mad at me, but she told the provider. She refused to document it. The provider held the patient's discharge to observe.
Was I wrong? I'm looking for serious feedback. The other nurse is really mad at me because the provider "reported" her. And to top it off, management told me that it was I who failed to communicate. The other nurse wasn't even working in my area; she was just passing through!
For your own future benefit, consider carefully the interplay of rules and nursing standards at your workplace. You say you are not allowed to d/c doctor's orders, but you also would not be on solid footing as a prudent nurse by taking and following a verbal medication order that you did not document - which is what happened.
If you are never allowed to enter or cancel any orders, that also means that you cannot accept and act upon verbal orders. To do so while following your workplace rule of not being allowed to officially document these is a major patient safety issue. There are other angles, though, too: What happens when you someday run across the physician who says s/he never ordered you to hold the med and now the patient has experienced some ill effect from not receiving it, for example?
I realize some of this has already been addressed and I'm not at all trying to flog you, but it sounds like you sort of think what you did was okay except for this other busybody messing it up. I'm just encouraging you to see it a different way. ?
You did right by asking your coworker to do the right thing after the fact. Regardless what s/he did next, I would've filled out an incident report. In cases like this I might ask someone to do the right thing, but I would also (without sounding punitive or threatening) inform them that under the circumstances and incident report is necessary and that I am going to file one.
I agree with most of this but some of what you said is a little bit confusing. I think I know what you meant but I will attempt to clarify with my opinion and you can tell me if you agree.
While the OP may not be allowed to take any verbal orders, she could have/should have (and maybe she did) remind the doc that he needs to d/c the order, then chart in the narrative the conversation that she had with the physician about the Haldol, including her reminder to d/c the order.
While I understand and would follow a rule to not accept verbal orders, it is certainly within the nurse's purview and scope of practice to refuse to follow an order that is to the detriment of the patient, which is why the OP, or anyone in her position, should document the conversation between nurse and doctor that explains why the order was not followed. While care should be taken in the wording, I would never follow any hospital rule or policy that forbade me to document such a conversation.
While I understand and would follow a rule to not accept verbal orders, it is certainly within the nurse's purview and scope of practice to refuse to follow an order that is to the detriment of the patient, which is why the OP, or anyone in her position, should document the conversation between nurse and doctor that explains why the order was not followed.
Yes, that would be fine, but it isn't likely to help others know that the med should not be given.
7 minutes ago, GM2RN said:
While I understand and would follow a rule to not accept verbal orders, it is certainly within the nurse's purview and scope of practice to refuse to follow an order that is to the detriment of the patient, which is why the OP, or anyone in her position, should document the conversation between nurse and doctor that explains why the order was not followed.
I get that, too and don't think you're wrong. It just doesn't necessarily sound like this angle was in play in this particular situation. It doesn't sound like the nurse was one with the initial qualms about the order nor the one who registered concern about the plan. A nurse making a decision to temporarily hold an order based on a concern is a different issue and also doesn't (by necessity) involve a verbal order. Rather, that would be a conversation that should result in an order being entered by the provider if they agree with the nurse's concern.
What I was trying to say is that if you are amending a patient's medication order/regimen based on a conversation you've already had with a provider, you are essentially following a verbal order. The nurse didn't officially cancel the order because s/he is is not allowed to do that....but you still need some other way to ensure that the (verbal) order you are following is entered as an order.
Yes, that would be fine, but it isn't likely to help others know that the med should not be given.
I get that, too and don't think you're wrong. It just doesn't necessarily sound like this angle was in play in this particular situation. It doesn't sound like the nurse was one with the initial qualms about the order nor the one who registered concern about the plan. A nurse making a decision to temporarily hold an order based on a concern is a different issue and also doesn't (by necessity) involve a verbal order. Rather, that would be a conversation that should result in an order being entered by the provider if they agree with the nurse's concern.
What I was trying to say is that if you are amending a patient's medication order/regimen based on a conversation you've already had with a provider, you are essentially following a verbal order. The nurse didn't officially cancel the order because s/he is is not allowed to do that....but you still need some other way to ensure that the (verbal) order you are following is entered as an order.
You're right that just documenting the conversation wouldn't let others know about the change in the order. I was attempting to address that issue by suggesting that the nurse should remind the doctor to d/c the order and hopefully he would do it soon enough to prevent a situation like this, but it's not a perfect solution. Given the way this particular situation worked out, the best outcome resulting from documenting the conversation would be to protect the (OP) nurse from accusations by management, showing that she had covered all of the bases as best she could under the circumstances.
I also agree that it's not exactly the scenario for refusing an order, but without a better idea, it's the best I could think of to support the (OP) nurse for not giving the original order.
There does need to be a way to ensure that the order being followed is entered as an actual order, but the nurse's hands are essentially tied in that respect since she has to wait on the doctor to do his part. The whole thing is a bit bizarre to me and a sticky situation for any nurse. Something needs to change, but until it does, I think the only option under the circumstances is to document the whole thing.
In my current workplace when pharmacy reviews Pyxis activity, nurse 2 would be called in for an investigation of why she administered a medication without an order ,who she had no involvement with and reported to state board of nursing.
For your own future benefit, consider carefully the interplay of rules and nursing standards at your workplace. You say you are not allowed to d/c doctor's orders, but you also would not be on solid footing as a prudent nurse by taking and following a verbal medication order that you did not document - which is what happened.
If you are never allowed to enter or cancel any orders, that also means that you cannot accept and act upon verbal orders. To do so while following your workplace rule of not being allowed to officially document these is a major patient safety issue. There are other angles, though, too: What happens when you someday run across the physician who says s/he never ordered you to hold the med and now the patient has experienced some ill effect from not receiving it, for example?
I realize some of this has already been addressed and I'm not at all trying to flog you, but it sounds like you sort of think what you did was okay except for this other busybody messing it up. I'm just encouraging you to see it a different way. ?
You did right by asking your coworker to do the right thing after the fact. Regardless what s/he did next, I would've filled out an incident report. In cases like this I might ask someone to do the right thing, but I would also (without sounding punitive or threatening) inform them that under the circumstances and incident report is necessary and that I am going to file one.
I did document that I was directed not to medicate the patient, as did the prior nurse who had given me report. I also filed an incident report, but I simply stated that 2.5mg was ordered and 5mg was given. I didn't go into further detail, right or wrong.
Also, perhaps I should have mentioned that it was a prn order, so my not giving the med does not equate to a scheduled med not being given, i.e. there doesn't need to be a reason that I didn't give it, per se.
Two questions, why was the other nurse even present? Why did she pick this random patient to medicate?
Honestly, because she butts into other people's business all the time. That, and she thinks she is smarter than everyone else. How she came into this situation, I'm not sure, as I was in another room with a guy in DTs at the time.
As far as the specific patient goes, I got report a little before midnight. The previous nurse had also documented that the pt. was confused and trying to get out of bed but that the haldol was to be held for the reasons I already stated. After this all played out, I asked the bedside sitter if the patient had escalated further and was told that she had been doing the same thing for an hour and had not gotten any worse. I think that the other nurse just walked through my zone and took it upon herself to give the med. My problem is that 1)she didn't ask me or the provider first, 2)she gave twice the ordered dose, 3)she wouldn't document that she had given it.
Update: Today my manager asked me where this all happened. They are investigating it and are going to review security footage. This is a little strange to me, because even if they decide the patient's condition warranted the meds, they still aren't addressing the overdose or the refusal to document. You don't need security footage for that. I'm wondering if the other nurse is either claiming that she never gave it or that it was I who gave it. I don't know, but if that's the case, they'll see the truth on the tape.
I would consider those actions as someone who is willfully trying to get you into trouble.
Yeah, that kind of crossed my mind. Too bad for her, tho. I have a great reputation and i've worked in this network for 18 years. Also, all the witnesses corroborated what I said. And now management is apparently investigating.
Specializes in UR/PA, Hematology/Oncology, Med Surg, Psych.
Sounds like they want to review the video tape to see if this nurse actually gave the med or drew it up and pocketed it. I would be suspicious of a nurse that had no reason to go into another area to give a medication and then refuse to document it.
Sounds like they want to review the video tape to see if this nurse actually gave the med or drew it up and pocketed it. I would be suspicious of a nurse that had no reason to go into another area to give a medication and then refuse to document it.
Agreed. I feel this may be a case of a RN who wandered into the ER hoping to snag some Haldol from someone and take it elsewhere. I highly doubt that any RN would happen to wander into another person's room and give meds for a pt that wasn't even theirs and twice the amount no less, and then refuse to document it. If that hospital uses Pyxis or any other electronic logging device to record who took out meds then that RN is going to lose her job and probably have the BON look really close at her. Security footage aside, there are cameras in many med rooms and security can easily see who took what out and when so that RN will be shown to be removing meds from a department that wasn't theirs, during a time they were supposed to be elsewhere (or not at work in the first place), and for meds that were already discontinued. She is doomed.
GM2RN
1,850 Posts
I agree with most of this but some of what you said is a little bit confusing. I think I know what you meant but I will attempt to clarify with my opinion and you can tell me if you agree.
While the OP may not be allowed to take any verbal orders, she could have/should have (and maybe she did) remind the doc that he needs to d/c the order, then chart in the narrative the conversation that she had with the physician about the Haldol, including her reminder to d/c the order.
While I understand and would follow a rule to not accept verbal orders, it is certainly within the nurse's purview and scope of practice to refuse to follow an order that is to the detriment of the patient, which is why the OP, or anyone in her position, should document the conversation between nurse and doctor that explains why the order was not followed. While care should be taken in the wording, I would never follow any hospital rule or policy that forbade me to document such a conversation.