a mess!

[muesli]

Today I had a patient who came up from the ED on a heparin gtt. When the patient arrived to the floor, I noticed the orders stated that her initial infusion rate per her weight should be more than what it was. I wanted to clarify with the MDs whether they wanted it changed. I looked on my computer which usually identifies the names of the attending followed by the name of the intern underneath. If it is a teaching patient, we go to the interns first. So I found that name, and was going to page him but I saw a young guy in a white coat walking through my patient's door. I said "Are you doctor (last name)?" and he nodded and said "I'm (first name)." I asked him the questions and he stated to increase the heparin gtt rate and draw the PTT 6 hours from when it was started in the ED. Later, the PTT was critically high and protocol was followed, and I paged the attending when this intern never paged back who confirmed how we should proceed. Then the attending told my this guy was a sub-intern and to page the covering hospitalist overnight for any concerns.

At the change of shift, I find out (Duh) that you're not supposed to change the initial infusion rate of a heparin gtt until 6 hours and the PTT is drawn, even if the initial rate differs from the new order for a standard weight based gtt. And then it suddenly dawned on me that a "subintern" probably isn't an intern at all - but a medical student.

So now I can't sleep, I'm sitting up thinking about what is going to happen to this patient whose elevated PTT might have been the result of an order by a medical student who I believe didn't correctly identify himself, carried through by me. I'm trying to figure out what to do about this.

[xtxrn, ASN, RN]

I'd find out who is supervising the med student , and tell them that Dr. Doolittle is saying he's a MD already, and verifying orders ... I'd also write up an incident report (better to do one on yourself and note the corrective action you'll do by getting clear IDs on those giving orders), to document this....NOT to get the guy in trouble. But, if this becomes (or is) a pattern with this idiot, there will be a paper trail if needed.... always CYA :)

[Simply Complicated]

I'm confused. Did you have an order to change it then once the patient arrived? You took a verbal order, and signed it the doctor you thought it was, or he wrote an order??

[vanburbian]

Well, if she is supposed to be on a heparin gtt., then the expectation is that she will indeed have a critically high PTT, that's the goal, right?

The first thing I would have done is check with ED nurse and ask why the rate was different than what was ordered.

At any rate, (no pun intended) this person implied he was the doctor you asked him about, so it's on him.

[msjellybean]

Well, if she is supposed to be on a heparin gtt., then the expectation is that she will indeed have a critically high PTT, that's the goal, right?

To an extent, yes. At my facility, we have a scale that is critically high, even while on a heparin gtt that if you fall into it, it warrants a phone call to the doc. I want to say it's above 150, but I'm not for certain.

xtxrn offers some excellent advice.

[vanburbian]

I am at a loss to explain why a med student would say he was the doc. If this in fact the case, I would hope he is seriously reprimanded, maybe even expelled. Harsh, I know, but these are the types who study nephrology and then want to perform plastic surgery.

[canesdukegirl, BSN, RN]

Oh honey, that is a hot mess indeed!

Yeah, you gotta write an incident report. This med student is treading on dangerous ground, and if he isn't reprimanded, he could seriously hurt someone.

Don't be so hard on yourself. You asked him if he was Dr. X, and he nodded his head. I am surprised that a med student would give orders. Did he write them as well? Or did you write a verbal?

Are med students rounding by themselves now? Probably a bad idea...

[muesli]

I'm confused. Did you have an order to change it then once the patient arrived? You took a verbal order, and signed it the doctor you thought it was, or he wrote an order??

Well, the order was entered by the hospitalist when the patient arrived to the floor. It was for a heparin gtt, but at a different rate than the rate at which they started it down in the ED. So, the order was already in, I just needed to verbally clarify that the rate should now be changed to meet the order that was now in the computer or if I should wait. It wasn't like I was taking a verbal order out of the blue, with no actual order to go by. I was just looking for clarification of an existing order.

[muesli]

Well, if she is supposed to be on a heparin gtt., then the expectation is that she will indeed have a critically high PTT, that's the goal, right?

The first thing I would have done is check with ED nurse and ask why the rate was different than what was ordered.

At any rate, (no pun intended) this person implied he was the doctor you asked him about, so it's on him.

Yes and no - there are acceptably high/therapeutic ranges, this was above therapeutic, >150. I like your idea of checking with the ED nurse. Thanks.

[Double-Helix, BSN, RN]

So you changed the heparin drip rate so that it matched the actual order, after checking with the "doctor" that it should be increased.

I don't see how that is a med error, since the rate was set as ordered. I just hope you documented "Pt received from ED. Heparin rate XYZ. Heparin increased to ABC per original order, clarified by Dr. X." Or something like that.

It does sound like someone in the ED missed a step- either setting the wrong rate, not documenting why the rate was lower, or not getting a new order to reflect the set rate.

[linearthinker, DNP, RN]

I agree. Write the incident report and let the chips fall where they may.

[Simply Complicated]

Well, the order was entered by the hospitalist when the patient arrived to the floor. It was for a heparin gtt, but at a different rate than the rate at which they started it down in the ED. So, the order was already in, I just needed to verbally clarify that the rate should now be changed to meet the order that was now in the computer or if I should wait. It wasn't like I was taking a verbal order out of the blue, with no actual order to go by. I was just looking for clarification of an existing order.

Oh ok. See in a case like that, personally I would have wrote a clarification order, or given the "doctor" a sheet to write the order on. But I NEVER do things without it documented. Was there an different order that pertained to ED? I know a lot of times we see things that the ED ordered, but it's in a seperate section. Crazy that he put himself off as the doctor though. Did he possibly not understand what you asked him? Or was it blatantly obvious he knew who you said?