Can I get in trouble for this????

[vanurse2b]

Please help!!! I recieved a patient about an hour before my shift ended (about 5:15am). In report I was told that she had been admitted for shortness of breath but there weren't any beds available so she had been on hold in the ED since 5pm the previous evening in another room. The patient was alert and oriented x3 and in no respiratory distress. Before my shift ended, i noticed her respirations were labored and she had audible wheezes. I noticed that she wasn't wearing her nasal canula so I reapplied it an her saturations increased. I then gave her a breathing treatment. She was still receiving the treatment as i was reporting off to the next nurse. I also reviewed her orders to check for any NOW orders, which i did not see. She did, however, receive a number of antibiotics and other meds sometime after she arrived to the ED by another nurse.

Unfortunately, this patient was intubated later in the day. The admitting physician is writing a formal complaint because he says she didn't receive any of her ordered meds. Like i said, i don't remember seeing any outstanding now medications. Daily meds are normally given as early as 8am (i believe) so there was nothing i needed to give her at that time in the morning (6am). Am i at fault, is the nurse who cared for her before me at fault? What happens in situations such as this? Please help...i'm worried sick.

[Roy Fokker, BSN, RN]

Start with the basics:

1. Did you carry out all orders before change of shift? You said you didn't see any "now" orders and there were no other meds ordered other than Protocol-PRN meds.

2. Was pt. in acute respiratory distress? You said pt. had mild wheezing and some low sats and you took corrective steps (NC, Nebs).

3. When you handed off at shift change, were you comfortable with it? Pt. was relatively stable and oncoming nurse should be able to assume care.

1. Check

2. Check

3. and Check

I see nothing wrong.

The only think I'm slightly confused about is that you mention being worried about 'not informing the Doc' but you also mention 'standing protocol for Nebs for SoB in the ER'. Soooo, where were you working? On the floor or in the ED? If you were working in the ED, why would you need to 'call the Doc' - aren't they right there in the Department? If you were working on the floor, how can you use ER standing orders?

Just a little confused

Then there is the whole issue of who is really caring for this pt now,.the ER doc or the admitting doc?

My understanding is that if admitting attending/hospitalist/resident has written orders for the pt., then they are now responsible for the pt's. care. If I need something or if there is a change in pt. condition, I have them paged.

I don't bother the ED doc unless it's a critical emergency (FDGB type scenario).

cheers,

[mpccrn, BSN, RN]

in our hospital, there are ED orders and there are admit orders....the admit orders do not have to be followed until the patient is admitted to a room (yeah, i know, it's ridiculous considering they may be in the ED for hours before a room is available). anyway, if there were no 'now' orders, and you treated her wheezes and decreased sats, the oncoming nurse should have gone to see her first....can't see that you did anything wrong. COPD'ers crump......that's the way of things....

[kmoonshine, RN]

Did they check ABG's on her to monitor her CO2 levels since she was getting breathing tx's and had COPD? If she was on oxygen at home, was that level maintained in the ED?

What meds could you have given her to prevented intubation (IV steroids take time to work, IV antibiotics take time to work...)? Its not like using insulin for high blood sugar - the SOB won't be "fixed" immediately. I know of no med that will reverse COPD and all the meds used for secondary problems r/t COPD (ie pneumonia) take time to work.

The patient was no longer in your care when she was tubed. You took care of her for an hour and then passed off report. She was A/Ox3 and tolerated the breathing treatment. As her condition changed throughout the day, it was the primary RN's responsibility (and not your responsibility since you had long gone) to notify the doc.

I don't know how orders are put in at your hospital - where I work, admitting MD orders go to the HUC who transcribes the labs and radiology; then, the orders are sent to pharmacy and they dose and schedule the meds.

Sounds like a communication problem at best and no single person can be blamed for this. It was the doc's responsibility to notify the primary RN that orders were written, and scribbling on a piece of paper and shoving it into the chart doesn't make the process any easier for us.

Don't beat yourself up. Ask to review the patient's chart and use this situation as a learning experience.

[BinkieRN, BSN, RN]

You could ask the doctor exactly what is disturbing him and tell him you would like this to be a learning experience so you won't mess up again, if he actually thinks you did mess up.

I wouldn't talk to the physician. Let management handle it. You did nothing wrong and may not even be involved. It could be that ER didn't send a complete set of orders or that they were her routine AM meds which you're not responsible for.

I think you took the appropriate steps for this patient with a known hx of COPD. She came through the ER because obviously she was in distress, I don't find it at all far-fetched that she would end up intubated, I doubt it had anything to do with lack of care on your part. Try to relax.