Low K level - possibly getting written up...

[uscstu4lfe]

I received a patient with a low potassium level of 2.6. During report, the ER nurse stated that he had called the MD, informed the MD of the potassium level, and that no new orders were given. So I get the patient on the floor, and about 5 hours later my boss hears of the level with no new orders and tells me that I HAVE to call the doctor now. So I did, and from the way he was talking, it sounded like he didn't even know, but he ended up ordering a few things. Anyway, my question is, I'm not sure how to handle future situations like this. If, during report, the nurse says that he/she has already called the physician and has made them aware of whatever the problem is, are we supposed to accept that? Are we supposed to believe they are full of it and call the doctor again to make sure? I'm just not sure...

[BrnEyedGirl, BSN, MSN, RN, APRN]

Not sure how it works where you work, but is it possible the ER nurse spoke with the ER doc and didn't get orders, but didn't actually speak with the admitting doc? Where I work, in ER, I would not call the admitting doc for abnormal labs, I would speak to the ER doc. Just a thought.

I've noticed many times that things that aren't necessarily emergent from the ER point of view are often addressed by the admitting doc.

[leslie :-D]

personally, i would need to hear it from the doctor him/herself.

and, would call to confirm.

leslie

[medsurgrnco, BSN, RN]

Unless it is clearly documented that the admitting doc was informed, I would call the admitting doc. That is too low a K level to not be sure the doc knows.

[Tweety, BSN, RN]

Make sure the previous nurse documented the call. Make it very clear and repeat what the nurse tells you "you called the MD, she's aware and there were no new orders received, and you documented this in writing?"

[uscstu4lfe]

i talked with my boss and she said next time something like this happens, to tell the ER nurse to write it as an order. she said nursing documentation isn't acceptable, and that it must be written in the physcian's orders that the doctor knows of the level, and that no new orders were given.

i didn't know we could write physician's orders like that, so good to know!

when my boss found out about it, she was pretty ****** off. i think she was ****** off at my at first and maybe didn't believe me. so she called the ER, spoke with the nurse, and he told her the exact same thing. then she appeared to be less ****** off at me, and then wrote an incident report.

[BittyBabyGrower, MSN, RN]

I don't know about writing it as an order.....what type of order...."don't do anything" and then you have to have it as a telephone or verbal order read back to the doc who in turn would have to sign it at some point. Documentation in the nursing note should be sufficient as long as it is dated and timed "Dr. smith called at 1800 and told of K level of 2.6. No orders given at this time." should be good enough.

[robred]

I think this falls within the patient safety category of which one cannot 'let sleeping dogs lie'. Just for the sake of argument, let's say that the ED physician decided to let the admitting manage the hypokalemia and the admitting was told errouneously or misunderstood the k level to be 3.6 instead of 2.6. If I found myself in this situation I would NOT accept another nurses's word or even another physican's at face value. I would personally call and verify with the admitting that he/she knows that the K+ is 2.6.

If he/she chose to still not supplement it, I would call my supe or manager. Case in point: I once had a pt who was a post-op day 3 with an NG to LIS that was pulling alot out who had 40meq in his hyperal who developed alot of ectopy on tele. I called the hospitalist to update him and was blown off. An hour or two later, the pt had an RonT and went into VF. We resuscitated him successfully and found his K to be 2.5 (it was 3.1 some 16 hrs before). This was a rude awakening to me and I thanked the Lord for watching over my pt....cuz I failed to. Unfortunately, the hospitalist didn't offer anyone an apology. The lesson here: Don't accept an answer when you know that it is an inappropriate one. In the end, your manager was within her right to be upset.

[Southern Fried RN]

Our hospital has a "critical lab value" form which the specific name of the ARNP/PA/MD was notified and at what time. Yes, it's another piece of paper to keep up with BUT it will save your butt when situations like this arise.

If I had been in that situation, I would have A) clarified which MD was aware (ED vs admitting) B)if the admitting MD was aware, run the situation by my charge RN C) Depending on the pt's diagnosis, checked to see if there were other consultants to get orders from (renal, cardiology). That K+ is too low to not get orders to cover. If the Hemoglobin was 5, wouldn't you keep calling to get an order to type & cross and transfuse? The patient's safety is at risk here. Just because an ED nurse passed on in report that a doctor was aware but didn't order and replacement is NOT going to pass muster if the pt coded.

[leslie :-D]

The patient's safety is at risk here. Just because an ED nurse passed on in report that a doctor was aware but didn't order and replacement is NOT going to pass muster if the pt coded.

exactly.

imo, it's poor nsg judgment to let it slide, even w/notes that state md aware and nno's.

leslie

[Nurse2Doc2008]

Oh my, as an admitting intern, I'd rather BE called twice than not at all for something like that. Absolutely, it's in the best interest of the patient, but we're also likely to get in big trouble for not doing something about a level like that, and the excuse, "the nurse didn't inform me" doesn't fly at all. And well it shouldn't, everyone shoud look up labs and make sure everything's covered........but I think we all rely on eachother to make sure everyone's in the loop with the patients, so I always appreciate heads up. even if it's the second time.

[EJSRN, BSN, RN]

I think this falls within the patient safety category of which one cannot 'let sleeping dogs lie'. Just for the sake of argument, let's say that the ED physician decided to let the admitting manage the hypokalemia and the admitting was told errouneously or misunderstood the k level to be 3.6 instead of 2.6. If I found myself in this situation I would NOT accept another nurses's word or even another physican's at face value. I would personally call and verify with the admitting that he/she knows that the K+ is 2.6.

If he/she chose to still not supplement it, I would call my supe or manager. Case in point: I once had a pt who was a post-op day 3 with an NG to LIS that was pulling alot out who had 40meq in his hyperal who developed alot of ectopy on tele. I called the hospitalist to update him and was blown off. An hour or two later, the pt had an RonT and went into VF. We resuscitated him successfully and found his K to be 2.5 (it was 3.1 some 16 hrs before). This was a rude awakening to me and I thanked the Lord for watching over my pt....cuz I failed to. Unfortunately, the hospitalist didn't offer anyone an apology. The lesson here: Don't accept an answer when you know that it is an inappropriate one. In the end, your manager was within her right to be upset.

What is a RonT?