I Need Advice - MD Not Signing Order

[Andrew, RN]

Hey everyone. I'm a RN working in a PACU. At my facility, CRNAs do the cases and there is one float MD that is there as a resource. We have "protocols" to give meds for pain/nausea without needing to call the doctor. The doctor then signs the order some time later, often not seeing the patient ever.

Here's my problem. I had a patient that just had a very painful ankle surgery. The surgeon wrote for a dilaudid PCA. I called the pain nurse to come and set it up. In the mean time, the patient was hurting at a "12 out of 10" and their vital signs/facial expressions reflected this. The pain nurse told me it would take her a while to get there and that I could give the patient some dilaudid IVP. Nothing wrong with that, we do it all the time. Basically, we are giving the patient their loading dose that the pain service nurse would be giving anyway once they get the PCA set up.

So, I give her 1mg IVP. Waited 5 minutes, gave another 1mg. The patient's pain went down and I left it at that. I wrote my order for it. The patient had a good outcome and had pain relief. This was earlier in the week.

Fastforward to today. I get called into my charge RN's office. The anesthesiologist is refusing to sign this order. I got sent home and they are going to talk to the pain service nurse later today when she comes in at 3 pm. I'm not sure if I'm going to have a job and it's up to "how far" the doctor wants to take this.

Basically, I was going by our protocols and giving the patient a medication in a manner consistent with its guidelines. I don't know what to do.

I wrote the order as "Hydromorphone 0.5-1mg IVP q 5-7 minutes MAX of 4mg" and I only gave 2mg.

This sucks. =(

[It'sMe, RN, BBA, MBA]

Some of this advice is helpful, some of it isn't. Thanks anyway for those who have commented.

Here's some facts. The hospital is not JCAHO so their standards don't apply here.

The pain nurse is a RN, not AP. They write orders all the time that later get signed by the anesthesiologist, just like I do, only they write much more... PO opioids, sleep aids, toradol, etc etc.

In the given situation, I have done nothing wrong. The patient had pain, I treated it using a drug that they were prescribed to get. It's a gray area I am in. Perhaps if I had given fentanyl (a drug the anesthesiologist seems to be more comfortable with) instead I would not be in this mess and the doctor would have signed the order, but I gave dilaudid because that is the drug the patient was to receive via PCA.

The pain nurses often times when setting up the PCAs will give a loading dose starting with 2mg and redose 1-2mg at a time. I've seen them give 4-6 before. Every patient is different and requires a different dose for dilaudid. To the person that says "OMG it's 8 times more potent than morphine blah blah blah"... It's 2-8 times more potent, depending on the patient.

I gave 1mg, repeated it, then stopped. There was no harm done to the patient. Nothing bad happened. They're just singling me out. I gave a normal loading dose that the pain service nurse would have given. She was sitting around in the breakroom instead of being at the bedside treating the patient's pain. So I did.

This is what I hate about nursing. Infinite responsibility and no real power to do anything.

Keep your chin up young man! This is a hospital and nursing administration problem. Forget JACHO, you have a state Department of Health (or whatever your state hospital licensing agency is in your state) and if I was your nurse manager and the DON I would be on top of this like white on rice! If there is even a hint of non-written standing orders being used the state department can come in and shut down your surgical services! Do you know how scared the Hospital Administrator would be of that possibility? He/She would have an immediate ulcer and have to go to another hospital and have it repaired! Surgical services, especially day surgery, is the lifeblood of the hospitals right now. The decrease is having an adverse impact.

You need to be supported by your NM and DON in this situation. Your DON better have a heck of a relationship with the CMO. The CMO needs to go to this MDA and tell him to get over it, resolve it and help write standing orders to cover this in the future. JACHO or not pain relief is one of the number one sentinental events that MEDICARE and MEDICAID are looking at and they pay 70% of the bills. You tried to do right and they simply need to move on and fix the things that need to be fixed. You are the good guy in this and not the heel and you need to hold your head up and help fix the problem. Good luck!

[Andrew, RN]

Hopefully I will get to keep my job and help them change their policies so they can be doing things the right way.

One of my friends got hired at this PACU the same time I did. She has 20+ years of Emergency Room and PACU. Here's what she had to say about this when I told her:

i heard absolutely nothing!! Be sure to bring pain service into the mix. They order things and don't tell you or don't explain what they want when we are not familiar with the "way things are done" it really makes you feel like they enjoy not telling you what the rules are. i mostly get that feeling from one person. she seems to think that the way they do things is the way it is done everywhere. They do things way different than what i was used to. we used a lot of dilaudid, and not in pca's. (at the other hospital we worked at) plus we could give a bolus from a pca without waiting for the pain person to return to the department. we are not oriented to the machines, they don't tell us what they are giving, and when you ask they act like you are retarded for asking. they tie our hands to treat our patients the way we want to. I think I would get patients out faster and more comfortable to give morphine then fentanyl. if they have dilaudid in the pca, then the best thing to do is not mix drugs. the time i like to mix is give morphine up to 10 then give a tiny dose of fentanyl. i mean tiny. stephanie uses that and it works great. you end up wasting 3/4 of the fentanyl, but only use one morphine and they are comfortable. also we gave smaller doses of morphine quicker. one mg every 2-3 minutes. 5 mg is a lot for some people, 10 doesnt faze others. ask them for more clarification of what is expected. also ask what way to document pain team ordering medications and if you should write the order from them, since they give it. (they write it from the float because they are not physicians.) i really did not hear a thing... keep me updated and i will keep my ears open and not let them know i heard from you

[wtbcrna, MSN, DNP, CRNA]

wtbcrna, it's not that you aren't raising valid points. The issue here is one of context. This is a new nurse who is working in a facility in which nurses writing these types of orders without an MD's order is the norm, and Andrew, RN, is taking the fall for it. This is something that has become an unofficial "protocol" where he works, and the new nurse who is doing what he has been trained to do by the experienced nurses who have come before him is the one being hung out to dry. Of course the anesthesiologist's concerns are valid (that he does not want to sign an order he did not give), but what we're really looking at here is a problem brought on by the facility's lack of written protocols, and Andrew, RN, the newbie, is caught in the crossfire. I agree it's a dangerous practice and needs to stop, but I don't agree that Andrew, RN, should bear this responsibility on his shoulders when this is a practice that has been in place and has been allowed to continue long before he ever set foot in that place.

Actually, you make my point for me quite eloquently, if you don't have written protocols and you don't have the training/advanced practice license then you shouldn't trust the MD or APN to come to the same conclusion that you have. It is your license that you have to protect just as it is that MDs license that they are protecting.

Don't get me wrong either just because I don't agree with AndrewRN giving the meds in that dosage over that amount of time doesn't mean I would advocate to have him fired or even written up. I personally would just explain why this isn't a safe practice, no matter what the other RNs at that facility do, and as long as similar situation didn't occur again I wouldn't worry about it. I wouldn't want to work at facility like that one either.

This should just be treated as a learning experience nothing more nothing less.

[Andrew, RN]

This MD isn't trying to protect his license. He's being passive-aggressive and overboard.

The dosage I gave of this drug in this situation was safe. I've never had one of my patients respiratory arrest. I've never had to give narcan or reverse one of my patients because of something I have done. I've had to bag patients and reverse patients because of CRNAs that gave elderly patients and/or patients with impaired liver metabolism/kidney function too much opioids.

The issue here is the facility and the way they go about "business as usual". I'll be in touch with a lawyer and my state board of nursing soon.

[sjt9721, BSN, RN]

This MD isn't trying to protect his license. He's being passive-aggressive and overboard.

The dosage I gave of this drug in this situation was safe. I've never had one of my patients respiratory arrest. I've never had to give narcan or reverse one of my patients because of something I have done. I've had to bag patients and reverse patients because of CRNAs that gave elderly patients and/or patients with impaired liver metabolism/kidney function too much opioids.

The issue here is the facility and the way they go about "business as usual". I'll be in touch with a lawyer and my state board of nursing soon.

The issue is that you don't see your error...all you see is that you got caught.

I'm not debating what drug you gave or in what dose. I'm not arguing whether your drug/dose decision was appropriate or not.

My problem is that you gave the drug without an order or written protocol to back you up.

Yes, I realize that this is the status quo for your facility. Yes, I believe your manager & co-workers should support you since this seems to be standard practice. But that is a different issue entirely.

Go ahead and go to the BON. You may indeed report the unsafe practices there, but don't for a second think that the BON will reward you by overlooking your role.

Your nursing license is about your practice. Using the excuse of "everyone does it" and "I was told to do it" won't abdicate any of your responsibility in the event. In the end, you made the decision to write & carryout an order and practice outside of your scope. That is all the BON will see.

I'm sorry that, as a newer nurse, you were the one to get caught. But that's the chance that we all take when we cross into that aforementioned "gray area".

Good luck to you.

[Andrew, RN]

I gave the drug with an order. The surgeon wanted the patient to have dilaudid.

[sjt9721, BSN, RN]

I gave the drug with an order. The surgeon wanted the patient to have dilaudid.

I'm just going by your own words in your first 3 posts of this thread.

[canoehead, BSN, RN]

I gave the drug with an order. The surgeon wanted the patient to have dilaudid.

I read the whole thread and I'm not clear on the order. I assume you had PCA orders with a loading dose, and maintenance doses and lockout times. What I understand is that the PCA machine wasn't set up yet so you gave the loading dose manually, and then gave the patient a dose that he would have gotten via the PCA, if it had been set up at the time.

Some readers seem to think you gave Dilaudid (per the order) but made up your own amount because the patient's pain was so severe, and the pain nurse was not available. If that is the case I agree it was poor practice, whether it's done all the time or not. Some patients can be bellowing and then go to sleep after 2mg morphine, when you'd swear they'd end up needing 10mg. If you happen to get a narcotic lightweight it's your butt when you don't have an order. I work in the ER and even though we have a great working relationship with the docs it's important to be meticulous about narcotic orders. You don't want anyone questioning your integrity on that front.

But how I read it you had the order, you just didn't have the machine attached to the patient. So you gave the drug in the amount prescribed and waited the prescribed time between doses. If that's the case I disagree with your manager, you were providing care as prescribed in a temporary fashion until the PCA was available. The fault would be in the system, or in the nurse responsible for having the PCA set up on time in that case.

[wtbcrna, MSN, DNP, CRNA]

I gave the drug with an order. The surgeon wanted the patient to have dilaudid.

Based on my understanding from you have posted here the surgeon wanted a dilaudid PCA started, which the pain nurse was supposed to set up, and hadn't gotten around to it. Then you took it upon yourself to give IV push dilaudid based on what you felt was appropriate dose not what was written for.

So in other words you didn't have an order for what you did, you wrote your own order to cover the IV push meds you gave, and then you expected the MDA to sign off your order that you wrote......This is all based what you posted here so correct me if I am wrong. I just cut out all the extra extraneous information.

[beachgirl17]

If the surgeon gave the order for the PCA and wanted the loading dose. Then why can't the surgeon sign off on the order instead of the anesthesiologist? I am not a PACU nurse, so I am curious about it.

[BradleyRN]

I wrote the order as "Hydromorphone 0.5-1mg IVP q 5-7 minutes MAX of 4mg" and I only gave 2mg.

I gave the drug with an order. The surgeon wanted the patient to have dilaudid.

You did not have an order. You wrote an order. I still do not understand why you wrote an order for more than you actually gave. What was the point of that? As wtbcrna pointed out and quite clearly, 0.6mg would be the initial dosage for a potentially opioid-naive pt, which could easily be the case with a post-op pt. And yet you write for 4mg? That was your mistake, and likely the reason that nobody is going to sign off on such an order. I hope this works out for you, but you must quit blaming others and accept the fact that you did actually make a mistake.

[RN1982]

I'm confused also. I thought the doc ordered a Dilaudid PCA. How did IVP Dilaudid get ordered? Did you get a verbal order from a doc? Or did you write the order assuming the doc would sign off on it? In my opinion, what you should have done while waiting for the pain nurse to arrive to start the PCA was call the MDA and ask for an order for IVP Dilaudid. I don't see anywhere in your posts that you were given an order for IVP Dilaudid. Usually, when I have a patient with a PCA, the loading dose, if ordered, is given via the PCA. What was the loading dose of Dilaudid that was ordered?