Messed Up Big Time

[snortzmom]

I've been an ER nurse off of orientation since October and I am so bummed out. I have been told that I am going to be written up, and I made an honest mistake. I thought people only get written up if they make a deliberate mistake, like talking back or showing up late. Last night I was taking care of a frequent flyer with chronic angina, COPD, diabetes, you name it this guy had it. Anyway, after 3 nitros the chest pain resolved. I walked into the room and the doctor was angry with the patient, and all I heard him say was "but you do what you want." The patient was fully dressed and said that the doc had discharged him and that he was ready to go home. So I went to the chart and the green tab was up, meaning that he had been discharged. I saw orders on the chart for the man to be admitted to the chest pain obs unit, and the discharge instructions were not filled out by the doc (though they sometimes aren't). So I thought that the patient had told the doc (who I couldn't find and the patient was mad bc he wanted to leave) that he didn't want to stay overnight.. I went ahead and discharged the patient, writing on the discharge paper "return with worsening symptoms." This is what I learned to do on orientation when the doc forgets to fill out the discharge instruction sheet. I thought I was being helpful. To make a long story short, turns out the patient lied to me and was never discharged by the doc. I was called by my boss right after I left and he told me that I am going to get written up and that the doc was really really upset. I thought I was doing the right thing!! I am so upset..

[traumaRUs, MSN, APRN]

If this pt was AAOx3, why didn't HE say something like "I'm suposed to be admitted."???

[nursemike, ASN, RN]

Getting "written up" is generally not the end of the world. Do you know what sort of write up your manager means? Is it an incident report, or a disciplinary letter? (At my facility, it would be an automatic incident report--which is not a disciplinary tool, but a way of analyzing what happened and how to avoid it in the future. With an incident report, you may be at fault, or no one may. We do an incident report whenever an admitted patient leaves against medical advice, but the patient has the right to leave, so the nurse isn't at fault if they do.)

It's possible your manager intends to write a disciplinary order for not following the doctor's order, or something along the line. That does count against you, in a way that an incident report isn't supposed to, but it still isn't the end of the world--usually. A lot of good nurses have been disciplined at one time or another. Most places use progressive discipline, beginning with a warning and "counselling" and only progressing to termination after repeated infractions, unless the first infraction is a big one, like gross negligence or abuse.

It would be good to clarify with your manager, if you don't know, which type of write up is intended. Both may apply--an incident report and discipline. But in either case you'll likely be asked to explain what happened, and it will help if you have some ideas ready as to how to avoid the same mistake, next time. Not taking the patient's word is, sadly, a lesson we probably all learn, and getting the doctor to clarify an ambiguous order is another one.

Best of luck. I won't say don't sweat it, but it does sound like an honest mistake. One of the difficulties in a profession where we strive to be perfect is that we inevitably fall a bit short, from time to time. I think what seperates the good nurses is that they continue to strive for perfection, anyway.

[Newandconfused]

I am not making light of your situation, as I am sure you have learned from it the hard way. But my clinical manager hands out write-ups to the new and to the old as if it were candy on Halloween night.

[mom2michael, MSN, RN, NP]

So....the story goes like this. The patient is dressed, in his right orientation, tells you he is supposed to be D/C'd, the tab is pulled (which means...patient is ready to go home). The doctors routinely do not fill out D/C instructions and so you did what you thought was right and you sent the patient home.

Sounds like more than 1 person dropped the ball in this situation.

Sure you should've found the doctor to ensure that all the ducks were in a row, but you didn't and a mistake was made (which I'm sure will NEVER happen again). BUT the doctor should not have pulled the tab and the patient should not have told you he was ready for D/C.

Write ups sound scary but they aren't always. They can be used as a great tool and in this situation, obviously there was some breakdown going on in the system all the way around and that needs to be addressed (like, don't pull the green tab UNLESS the patient is actually ready for D/C).

I work in ER, I know you can be so busy and trying to get everything done yesterday......so sometimes it can be a whirlwind of confusion.

It will be fine. I remember way back when before I was in healthcare, I had NEVER been written up, got written up 3 times in 1 week....all by the same person. Boy did I feel like an idiot. But it helped in the end because we (myself, supervisor and our manager) were able to figure out ways to make the system better in the end.