14 Nurses Fired and 9 disciplined in Kentucky

mattsmom81 · Oct 21, 2003

Night Owl, perhaps the med orders are in the form of an algorithm sedation protocol that goes on the chart in a stapled packet...as part of the DR's orders. That is one possibility only, as this is how the pulm orders come to us in my ICU.

Now in my situation, the docs set it up that way, but their system has created problems that are NOT being managed appropriately. If the admitting nurse does NOT immediately bring up the sedation protocol question from the admitting doc, there starts the problem. With after hours docs unwilling to make a decision for the other...it sets up a difficult situation.

I can see by the posts if one has not worked in this type of unsupportive, coercive ICU environment it is hard to understand.

Let me try to present one scenario:

Now, a restraint only does so much good on an agitated ventilated patient who bites and bucks needed ventilation. One can only calm and reassure so much. 'Fight or flight' takes over and the nurse is left to consider the harm THIS can cause. You have a sedation protocol in the doc's standing orders, no definite order to NOT use it, a patient in trouble, AND an on call doc who won't make a decision for his partner who is unavailable: so what to do???

A very seductive, dangerous thought in this uncertain situation: "I should do what's best for my patient", and give the Diprivan or Versed. Ask questions later.

Now the OP's story has hit home with me, cuz I find whatever I do will be wrong to an unresponsive management team and angry, abusive docs. It's possibly the culture of the fired nurses' place, as it is mine.

I hope these nurses have records of bringing the problem to management, and something they can defend themselves with. I hope their BON will see how facilities and docs create these types of scenarios, and place nurses in tough positions. I hope to see more details on their situation soon, as we can only speculate.

As for me I cannot judge them guilty without knowing all the facts. It is IMO unlikely the nurses alone are at fault here.

Sorry so long, guess I'm tired of the battle today and needed to vent a bit....

sbic56, BSN, RN · Oct 21, 2003

Originally posted by night owl
You would think that out of all those nurses, one of them might have said, "where's the written order?" Where's that ringing clue phone gif???

The fact that 19 nurses were nailed for same thing is exactly why I suspect something just doesn't measure up! Believing all these nurses were negligent, stupid or whatever negative label has been pinned on them, shows the ultimate in naivety, IMO.

barefootlady, ADN, RN · Oct 21, 2003

I agree that there is a skunk in the wood pile on this one. I think there was a standing order for this med but the nurse, unit clerk, etc did not bother to apply it to the chart when it was implemented. I NEVER take a telephone order w/o asking another RN to listen in and cosign. I found out a long time ago that any doc, no matter how nice, will deny, deny, deny they gave an order if they are in a bad mood. I will call and call if the doc does not like it, too bad, I have told docs I will include their "do not call" order on the chart and even while they are cursing me I say, "thank you" and hang up. I had one doc come in late one night because I kept calling about a patient that was in extreme pain, change in VS, change in sensation to leg, etc. He came storming in around 2 A.M. and within 15 minutes he was calling in a OR team for an emergency embolectomy. I felt very good that I had not let his rep for abusive treatment regarding late night phone calls discourage me from doing my job as a nurse. Bottom line, cover your butt, ask another nurse to listen to phone orders and cosign, report abusive language to supervisor and write doc up and give copy to manager, even if they do not take action, it will help you vent. Attempt to remain professional in these types of situations. NEVER let them see you cry, take a break and go off the floor when possible, cry in the bathroom off of the floor, but Apple a cool cloth to face before going back to floor. Other staff may or may not support your stance, but ALWAYS protect your license.

night owl · Oct 21, 2003

Originally posted by barefootlady
ALWAYS protect your license.

And that's the bottom line!

OC_An Khe · Oct 22, 2003

I am curious as to what percentage of the unit were represented by those 23 nurses. Do any of you know?If it is a significant percentage then the unit administrator had to be aware as well as MDs and Pharm. Were any of those people disciplined??? Yes something doesn't add up. Of course the RNs do need legal counsel.

deadend · Oct 22, 2003

Iam curious as to a situation that is occurring in a facility where my friend works here's the scenerio:

A patient was dx with scabies, several patients since developed the rash but when sent to the derm DOCs they are not dx-ing scabies the medical director ordered all the patients on the 2 floors be treated with Elmite. She says now several staff persons including laundy, and housekeeping have developed the rash with itching she says her DON and the supervisor have been giving the staff the Elmite cream with instructions on proper use and telling them to go and see their Doctor. My question is Isn't this prescribing? What are the legal ramifications for this? What do you do you cannot let the staff just itch and potentially spread this. Any one out there dare to tackle this one?

cannoli · Oct 22, 2003

I don't know the answer to that question, but I do know of a nurse that had a "rash" & "itch", and the doctor wanted to treat for scabies, which the nurse knew she didn't have, and then after she was seen by a different doctor, who ordered lidex cream figured out for herself that it was a reaction to latex, which the second doctor then said suspected latex allergy.

I've never heard of ELmite, but even the docs don't always get it right every time.

Sekar · Oct 23, 2003

Originally posted by sbic56
Sekar

I wonder if your experience has been different because you were in the military?

Well it might be a consideration, except that not all of my experience is in the military. 40% of it (counting moonlighting and time in nursing since retirement from the Army) is the civilian trenches with the rest of y'all. I've re-read the article and all the postings and I still think there is strong sense of "conspiracy theory" paranoia at work here. Is it really just an exercise in union busting to fire someone for breaking the law if they did indeed break the law? It may be killing the proverbial two birds with one stone, but the fact remains that somehow these nurses did something that left them legally open to diciplinary actions. HOWEVER, we don't have all the facts. All we have to go on is that article which is woefully short on facts. I still doubt that they administration could manufacture 19 cases of passing medications without orders so perfectly that it was undetecable. Administrators just aren't THAT good, no one is. There is always evidence of tampering if you know how to look for it. It is too big a cover up, too great a chance of getting caught. One or two nurses, maybe. 19 nurses worth of evidence changed or manufactured? I think not. We're back to the conspiracy theory. "It's not my fault, they are out to get me"

But let us set aside the "conspiracy theory" arguments. Let us assume that the administration really was gunning for those nurses. Then we know for certain that the nurses in question were stupid. Why do I insist on using the word "stupid"? Because we were all taught to TRUST NO-ONE. Get the order in writing or legally the order DOES NOT EXIST. Verbal Orders? Better get a witness on the line. Facility precidence? Are you going to put your license on the line for the sayings "it was always done that way" or that the doctor would "sign the order later"? If this facility has a history of firing those it perceives as trouble makers than those nurses were doubly stupid for not following the letter of the law. Face it, if the administration were after those nurses, then the nurses gave the management the ammunition they needed to get rid of them. They lost their jobs and they have no one to blame but themselves. They knew better than to administer those meds without orders and they knew better than to trust the physicians and the administration. So "conspiracy theory" or not, they brought it on themselves. Now they are paying the price.

Climbing on a soap box Perhaps that is a hard line to take, but if the nurse next to me in the MASH unit, during front line combat, didn't do their job my patient could die and so could I. As far as I am concerned you should do your job, do it right, take responsibility for your actions both right and wrong. One of my favorite quotes from the Army is "the maximum effective range of an excuse is zero meters". Expect no less than the best of yourself or those around you. Professionalism is our hallmark, or it should be as our patients deserve no less. If you have a problem with that, then you need to leave nursing and go flip burgers or dig ditches or something where people don't die when you fail to deliver your best. If my passion on this subject annoys or offends you, oh well. That is my opinion, I'm entitled to it, and I'm free to express it (I spent 20 years of my life ensure all of us have that freedom). Any of you who disagree with it are free to do so as those 20 years I spent in the Army were also spent ensure YOU have the right to disagree with me and to express it. OK here is the soap box, it is your turn...

Dayray, RN · Oct 23, 2003

This Gerber person is obviously not a nurse. If she/he were this would have been handled much differently.

It sounds to me as though even though there weren't written standing orders it was implied that it was okay or ever required to give dipravan. I would be very surprised if the doctors of those patients didn't know or even expect that this was done.

I only worked in ICU a short time but I work on L&D and we give tons of meds based on standing orders. Now I have actually read those orders but when I was brand new I just took the word of my preceptor that they were there.

Even with standing orders there is risk to the RN. Written orders can be interpreted many different ways and they always add that wonderful phase "clinical judgment". Conversely if a patient had an adverse effect because I didn't act on a standing order it would be my butt.

Also, It's called Milk of amnesia not mothers milk lol

sbic56, BSN, RN · Oct 23, 2003

Another thing that strikes me:

This had to have gone on for quite some time in order for the company to nail 19 nurses. If the facility were truly worried about patient safety, they would have nipped it in the bud. There is no way I can be convinced that "no one knew". Whether the practice was by the book or not is not the issue. I'll bet my bottom dollar that this was a well known and accepted practice. When administration wanted something on these nurses, they then decided to use this.

SJSU_Mami · Oct 23, 2003

This place the nurses worked at needs to improve their standards and make regulations clear. Employees should be taught clearly what their roles are. How sad for the nurses and the patients.

PMHNP10 · Oct 23, 2003

Originally posted by Sekar
Verbal Orders? Better get a witness on the line. Facility precidence? Are you going to put your license on the line for the sayings "it was always done that way" or that the doctor would "sign the order later"? If this facility has a history of firing those it perceives as trouble makers than those nurses were doubly stupid for not following the letter of the law. Face it, if the administration were after those nurses, then the nurses gave the management the ammunition they needed to get rid of them. They lost their jobs and they have no one to blame but themselves. They knew better than to administer those meds without orders and they knew better than to trust the physicians and the administration. So "conspiracy theory" or not, they brought it on themselves. Now they are paying the price.B]

As for the getting a witness on the line for a phone order, I'm thinking this isn't feasable 100% of the time. In fact I doubt many could say they do this often, if at all. In retrospect we should 100% of the time, because at any given time a MD could utter the words.."I never gave that order"--be it for an amiodarone drip or MOM.

Nonetheless, I agree the nurses brought this upon themselves bottom line. They gave an unordered med (assuming we aren't missing a key fact like the MDs or someone later went into the chart and removed the orders to give the meds). I don't think many will argue with you on that basic point. Problem comes in that this wasn't a 1 time occurrence; it was an ongoing situation. And unless the management, supervisors, pharmacy, etc are oblivious, they had to have known this practice was occurring for a period of time before the disciplinary actions were implemented. It's not like you can walk up to a shelf and take a bottle of diprivan off of it like you would a gown or clean linen. So why wasn't this practice haulted much much sooner? And why aren't some of the higher-ups sharing a bit of the responsibility for allowing this to go on to such an extent.

Another thing that comes to mind is--and this bugs me more than anything--WHY WASN'T there something ordered for the vent pts? Does this not seem a bit odd that a group of MDs just happened to forget to order some sort of sedation for their vent pts? I'm gonna make an assumption that all of the ICU MDs were not 1st day residents who have no idea about caring for someone on a vent. Sedation for a vent pt is like insulin for a diabetic pt--it's a given and a must. There are occasions someone might be in a hurry and forget, and there are of course exceptions to the rule, but certainly several MDs would not make such an oversight (nor that many exceptions to the rule) over an extended period of time. There is no "conspiracy theory" thinking here, it's just a question.

We obviously do not have the whole story, but whatever that story is, at the least, there are some shady goings-ons--some getting disciplined, some not, etc. So all this does is to give a big loud reminder to anyone who had any question of why there is such a nursing shortage. And make no mistake about it, occurrences such as this one aren't going to help that problem get better any time soon. And that is the shame in this situation, no matter the circumstances.

On an aside, my favorite Army saying is "hurry up and wait."