Forgot to follow up on orders

[JMK04]

Feeling very ashamed today. I need to vent to my fellow nurses and please do not judge.

I'm an RN working in home health and forgot to follow up with my Clients PCP regarding a urine specimen which is where this story begins.

My client has a Foley catheter and a history of frequent UTIs. The Patient was complaining of UTI signs and symptoms and I attempted to collect a specimen but didn't have enough urine for a culture.

i notified the PCP's nurse and my DON. The nurse stated she would call in a script and still wanted a urine culture.

She requested I follow up with her once the specimen was collected. I informed her that the caregiver would attempt to collect a specimen as I was already gone and would not be returning to the clients home that day ( Friday). I also informed her the lab was not open on weekends and the likelihood of submitting a specimen on Friday was slim and that we could try again next week.

Another nurse visited with the Pt on Wednesday and contacted The PCP, again regarding the UTI signs and symptoms and informed them she was unable to collect the specimen as well, she also asked about the Abx Rx as the patient never received it.

Another 9 days goes by, I'm visiting the Pt and notice no Rx was filled for antibiotics and called and reported this and the signs and symptoms to the PCP's nurse.

She was hostile on the phone and stated she was waiting on the culture before sending the Abx and that I failed to follow orders, delaying treatment.

She faxed new Med orders to my agency and wrote directly on the order that I had failed to notify the doctor.

Thankully the client is doing ok.

But I'm worried about being reported to the board by the PCP.

I take responsibility for failing to follow up and clarify the orders.

I've spent most of the day agonizing over the situation and thinking of what I could have done differently.

[NurseCard, ADN]

Whoever is responsible for scheduling visits should have scheduled

a visit on that Monday. Your DON, when you informed them that you

were not able to get the specimen... your DON, or the Case Manager,

whoever, should have scheduled a visit for the following Monday instead

of waiting until Wednesday.

Then, whomever went out on Monday should have taken perhaps a brand

new sterile foley bag, hooked it up to the catheter, and obtained the

specimen.

I'm not seeing how this is completely your fault, really. You did try to collect

the specimen, and then when you couldn't, you let everyone know.

If you didn't, I might have emphasized to your DON, or Case Manager,

or scheduler... that the patient NEEDED to be seen asap on Monday,

so that the specimen could be reattempted at that time.

If the caregiver could have somehow collected a specimen

over the weekend, couldn't the specimen also have been taken

to a hospital lab?

[Daisy4RN]

It doesn't sound like this was your fault (based on what you said here) unless you are the acting CM for the patient. You notif the MD and your DON. It sounds like the ball was dropped by the nurse that went the following Wed, that nurse was responsible for letting the MD know that specimen wasn't obtained, and also that this was the second attempt (because there could be a problem if you are not getting enough urine for a specimen). So, it sounds like it was either the 2nd nurse, DON or CM that failed to follow up. I hope that you documented your findings (to the MD), and who you reported off to (the DON). Either way, lesson learned for next time, follow up appropriately and document.

I do agree with above poster that you could have emphasized the need for follow up with the DON/CM, but that alone doesn't make it your responsibility.

[Kooky Korky, BSN, RN]

Not a Board situation, IMO. You made an error, sounds like lots of people made errors. Accept no more than your fair share of the blame.

Try to ferret out the reason no one followed up so nothing like this happens again.

Make sure everyone knows what happened and why. This is a teaching moment.

What does your boss say? How is the patient?

Lab closed? What would have been done with the specimen if one had been obtained?

How much urine is needed for a culture?

is this patient in renal failure? Dehydrated? Nearly anuric? Foley still in? Bladder distended?

How miserable is she? Coherent?

[Decitabinequeen]

It looks as though you acted appropriately! You weren't able to obtain a suitable sample and PASSED IT ON IN REPORT that it still needed to be done. That no one else did it is the scary part of the story. Can you really not trust those you work with to do their job?

[TriciaJ, RN]

I think a big chunk of culpability lies with the PCP's "nurse". She likely isn't a nurse, by the way. It sounds as if it was her perogative to withhold calling the prescription until a culture is received. She knew the patient had a history of frequent UTI, had symptoms but was waiting for the culture that you already said you couldn't obtain?

In a patient with a foley, a history and symptoms, the UTI should have been treated empirically, culture or no. The PCP's MA (since that's what she likely is) should have passed on your info to the PCP. It should have been his/her decision to treat empirically or hold out for the culture. By the way, even if a culture could have been obtained, it still takes a few days to show results, so treatment is still delayed. She should have been started, based on symptoms, on the antibiotic that was most recently effective for her. If the culture shows lack of sensitivity or resistance, then the drug can be changed.

I think your DON needs to have a word with the PCP and develop a better protocol for treating UTIs in a timely fashion. Sometimes, for whatever reason, specimens can be hard to get. Leaving the whole situation in the hands of an MA is just bad practice.

[neuron]

I wouldn't worry about the PCP reporting you. Likely they are not concerned about the patient anyway. Many a times I've tried contacting a PCP for an order only to be on hold for an hour by their 'staff' or a no phone call back.

In home health, the PCP has less responsibility. I find it's like talking to myself sometimes.

[Nipper48]

This is the classic "Swiss Cheese" of small issues that become a big error... Your agency needs to develop a new protocol to follow up in these situations, especially if there are multiple field staff seeing the patient. You reported it off and you are the one that really found the antibiotics were never prescribed. This is not a Board issue for you but a complaint from the provider or family to the state or Medicare Hotlines could have resulted in an agency complaint investigation or a full blown audit from the state or your accrediting body.