MD refuses to sign a telephone order.

[modernhippie_, BSN, RN]

I'm a new grad working on my own for almost a month now, starting in ICU at a hospital where the acuity of the patients is rather low, so I consider it a SICU. I had a pt with a history of cvs with right sided weakness. She was obese and refused her scd stockings. I knew this woman was a huge risk for clots, so I educated her and charted the education and her refusal. To cover my butt, I called her attending md to let her know, and asked if sag wanted to try an alternative DVT prophylaxis. She stated ..this pt was on a Helprin protocol right? I said yes but it was stopped. She said ok give her 30mg lovenox sq daily. I wrote it down on the chart and got the med from pharmacy. Gave teaching to pt on lovenox and administered med. I documented a MD notified for the refusal and that new orders were received. I get a call a week and a half later from my unit manager saying that the dr refused to sign the order because the pt has HIT. They sent a HIT test out during the shift prior to minr, but I hadn't seen the results and not sure if they were even back yet. The unit manager asked if I was sure it was tht dr I spoke to. I said yes, and in the chance that it wasn't, it had to be someone who was covering for that dr since they were clearly aware of who the pt was, even stating to they knew she was previously on a Heprin protocol. The mgr told me I need to be sure, and asked if I'm trying to say the dr was lyng? I was shocked!! I told her to check the phone records and see if that particular MD called on the date and time tht I charted her telephone order. She said she can check to see who was on call tht day. I JUST got my license a few months ago, and I'm shaking at the thought of loosing it over a matter of her word against mine. When r they going to start recording every phone call so ths doesn't happen. I am so angry and I wanted to know what I could do to prevent this from happening again, if anything.

[eatmysoxRN, ASN, RN]

First off, why would you call a low acuity ICU a SICU, which in my mind stands for surgical intensive care unit?

Next... As for your actual concern.. I highly doubt you should be worrying about losing your license. Sounds like the doctor is being a jerk though. It's impossible to prove that the physician told you that order, but it wouldn't make sense for to write an order for Lovenox without an order. Why would you? I see some nurses write for sleeping pills or pain meds sometimes if a patient complains at 2 am. Anyhow. I wouldn't worry. It sounds like you documented well.

[modernhippie_, BSN, RN]

Sorry I meant micu... We don't do too many a lines or invasive cardiac monitoring or cvp and stuff. Thank you for your comment. I'm thinking maybe with this particular dr I should keep phone orders to a minimum, and maybe not carry out verbal orders at all. Ask her to write them down since she's here then carry it out b

[TopazLover, BSN, RN]

I suspect the issue is one of hind sight for the doc The order was not correct given the info when the chart was complete with the new labs. Do you have hospitalists? Is is protocol to call the attending for these things? Is there a way you would have known about HIT. I do not know what it is, a test? a diagnosis? Sorry, I am retired and some things change while others stay the same.

I also doubt that you have any fears over your license. See how it is played out by your NM. She/He should not allow you to be hung out to dry on this. Is the patient OK? If no harm was done then it is learning. Hopefully you will not have to call this doc at night too often. Find out from your NM how you are to handle further phone orders. Review your policies on phone orders. Look for solutions and be willing to talk with your NM about solutions.

[Rose_Queen, BSN, MSN, RN]

This is why EMRs with CPOE are a great idea- doctors can enter their own orders from home (and my facility actually requires it- exceptions for not being at home with a computer, such as if out for dinner, or physician is driving- and then they are required to remain on the line until the nurse finishes entering the order in case alerts come up that would require changing the order). However, if that is not an option, I would have a second nurse speak with the MD and confirm. Two against one are odds I'd want on my side.

[psu_213, BSN, RN]

Sorry I meant micu...

That still does not mean its low acuity. The M stand for medical (not minor). Maybe its something like intermediate care.

[netglow, ASN, RN]

OK, no. None of you work with the OP. So cut the crap about the acuity of her workplace, PLEASE. Sheesh.

[psu_213, BSN, RN]

OK, no. None of you work with the OP. So cut the crap about the acuity of her workplace, PLEASE. Sheesh.

Why is this crap? We are not trying to make the OP feel stupid. I think it is legitimate make sure that the OP can correctly describe the unit to others (better here than in his interview for his next job).

To the OP: unfortunately you are stuck in he said, she said battle with the doctor. Write down the facts for your own use (just be sure not to use pt identifiers--you don't need a HIPAA issues on top of it all) so that way you don't get accused of trying to add information later in the process. Stick with the facts when speaking with your manager/administration/etc. when dealing with this. I really don't think your license is on the line considering this is Lovenox. However, I think it is important to tell your side of the story to others. I hope it works out well for you.

[Mulan]

Are you not sure who you talked to? If that's the case, in the future make sure you have the correct name, ask him/her to spell it.

Maybe you should make out an occurrence report as to exactly what happened, just the facts, nothing else.

Years ago a friend of mine called a doctor on New Years eve for something for nausea for a postpartum patient, the doctor later claimed he never ordered whatever drug it was that she gave.

It sounds like this patient should not have had lovenox ordered due to the HIT and this doctor is just trying to cover her ass, unless it wasn't her that you talked to. Even if she didn't have/wasn't given that information, she still gave the order.

A week and a half later? Is that when she refused to sign it or when you were told about it?

A doctor should have seen the order and the test result the next morning when they came in to visit.

[DoeRN]

That sucks. It happened to me once but we had our own personal phones one the floor and I was able to prove that I did call the doctor and they called me back. So he had to sign the order. He said he never talked to me and refused to sign the order. Thank goodness I never erase numbers. From now on have a second nurse verify all telephone orders.

[cstrazis]

The communication between you and the MD was too casual regarding heparin. Heparin is a dangerous drug, and it's D/C in such a high risk patient should have sent up a red flag. Sudden D/C of heparin without Coumadin coverage seems like an emergent response to an adverse reaction, such as HIT. Also, if you had known a HIT test had been done, though the results were pending, this should have sent up another red flag. HIT testing is done in response to a suspected problem, and administering lovenox when you knew the possibility of heparin induced thrombocytopenia existed- as lovenox is a low molecular weight heparin- was careless. You were just following orders and you are human, but nurses must be vigilant and question orders at times. The MD ignored the same red flags you did, or failed to investigate the patients' case ( sudden heparin D/C, no coumadin overlap, overweight CVA client=???----> HIT test pending) The MD may not have remembered the conversation he had with you, and knew that he would have never knowingly ordered lovenox for someone with HIT. He may be lying, confused, forgetful, heck he may also be inexperienced. Pointing fingers wont protect the patients or fix the problem in the future, but begin to recognize high profile medications like heparin or insulin with reverence- and a touch of fear. No matter what medications you patients are on, be vigilant, and do your homework before calling the MD, look at labs, history, vitals, really stick to SBAR- and use critical thinking so you can protect yourself and your patients. You did a good job advocating for your patient who was at such high risk for DVT but the patient was put in more danger for DVT in reality (HIT ironically increases clients chances of clots); Doctors are humans too, believe it or not ;] hang in there, with experience the process will become easier. Remember the themes we learn in nursing school- collaboration, accountability, advocacy and competence. Good luck!

[Ginger's Mom, MSN, RN]

Pharmacy should have been aware of the hit order too. The doc is being less than honorable.