Norton Audubon Hospital in Kentucky fired 14 nurses and disciplined 9 other nurses for sedating patients with Diprivan without an order. The hospital has also notified the Kentucky Board of Nursing of the matter.
As nurses we have to make sure that we are practicng within our scope of practice at all times, regardless of the practicing setting (home health, ICU, med/surg, etc). Practicing outside your scope of practice (LPN, RN, APN, etc) can lead to employment (disciplinary action taken in the workplace), administrative (Board of Nursing investigation), and/or criminal (practicing medicine without a license/certificate, which is a felony is some states) investigations.
I am not big on conspiracy theories but there is more going on here than meets the eye. I've been a nurse for many years, worked in a varity of settings and observed a great many practices that I felt were questionable. I know form experience that ICU nurses are often given more discretion than say Med -Surg nurses. The nurses in question may need to accept some type of disciplinary action due to their practice of nursing.
However, it seems to me that now is the time to call in the BIG GUNS to look into the overall practices in that hospital. There is no way management was unaware of what was going on. There is no way the doctors were unaware of the common practice nor is it possible that the doctors did not condone the common practice. Leadership comes from the top. Apparently the leadership at this facility saw no reason to question or correct the comon practice until it was recognized as a means of punishing those experienced nurses for speaking/acting to protect patients by advocating for a union. thr Big Guns that need to be called in to do a full and complete investigation are; Kentucky Dept. of Health, JACHO, Center for Medicare and Medicaid, The State Nursing Association as well as the Board of Nursing, Federal Labor Relations Board and any Association that certifies the specialty practice of nursing on the nursing units involved.
While I do not condone practicing outside of your license, I do know from experience that there are times that a nurse must take an action in order to protect a patient or risk an undesired outcome that could include serious harm or death.
I also believe that the State Medical Board should be initiating active and in depth reviews of the medical practices of any physician involved in this case. After all, if orders were not written and there is no standing protocol to address the omission wouldn't you consider that malpractice? I would!
To the nurses involved I want to say "Bravo for protecting your patient's from futher harm." I also must acknowledge that each of you should have known better. I will be deeply saddened if the choices you made are held against you. Having to stand before your Board of Nursing and accept a letter of reprimand be placed in your file would be one thing; any corrective action beyond that is overkill as far as I'm concerned.
There's definitely a rat in the wood pile in Kentucky. Hope these nurses have good lawyers.
Hopefully these nurses will file for wrongful termination complaint just as the others did. While we should never put ourselves in such a position, we all know how management works and the games they play. This is a good example as to why every nurse needs to know and understand legal principle of tacit or the Doctrine of Tacit.
Simply put, it is something stated or understood by inference or silence. Black's Law Dictionary states;
"Existing, inferred, or understood without being openly expressed or stated: implied by silence or silent acquiescence. As a tacit agreement or a tacit understanding. Done or made in silence, implied or indicated, but not actually expressed. Manifested by the refraining from contradiction or objection: inferred from the situation and circumstances, in the absence of express matter."
It seems to me that if this was a standing practice in which management stayed silent on, then tacit surely applies. In addition to filing a complaint with the Labor Board for discrimination (against union supporters), I would hope they would file a class action suit based upon following instructions by tacit.
This would help by making management more accountable. They would have to stop sticking their heads in the sand and ignoring such situations until it is convenient for them to address it, - - - - ie: get rid of the "trouble makers."
As an aside, one reason that I've always believed that there is more going on here than meets the eye, is that my facility tells us that Diprivan is very expensive, and we even have guidelines fr who can get it - as opposed to Versed. In addition, there is pressure to transfer those requiring long-term sedation to cheaper drugs after the first few days on Diprivan. So, if this is such an expensive drug, I fail to see how bottles could have been disappearing out of stock without someone noticing. Especially since most facilities now have unit dosing, Pyxsis dispensing of meds, and other very accurate systems to decrease med errors and ensure correct billing.
And, didn't the attendings and/or residents notice pts were sedated when they rounded? None of these pt's had MD assessments in their charts that noted they were sedated? If that's occuring consistently, that sounds like pretty poor practice on the physicians' parts to me. Weaning people off vents is the usual expected outcome, so at least some of these pts would have had weaning trials sooner or later, which means that some MD would have had to notice they were sedated, as it would be impossible to wean them while they were still sedated.
In addition, there would have been plenty of other hard-to-explain evidence of sedation. Even if we assume that NO nurses charted sedation ratings, or documented periodically briefly turning off the sedation to assess the pt's underlying neuro status and document it. Let's say a pt was fighting the vent, and was then sedated. Heart rate and blood pressure could drop with adequate sedation. Heavy sedation might require a change in the mode of ventilation, or might produce a change in the number of breaths "over" the vent per minute. All of these parameters are usually documented at least hourly. And no non-nurse - no MDs, no respiratory therapists - noted this on multiple patients? Hard to believe.
Why no mention of the pharmacists that supplied the stuff? Even if there was Diprivan laying about all over the unit, it had to be accounted for somewhere.
[b While I do not condone practicing outside of your license, I do know from experience that there are times that a nurse must take an action in order to protect a patient or risk an undesired outcome that could include serious harm or death.
I also believe that the State Medical Board should be initiating active and in depth reviews of the medical practices of any physician involved in this case. After all, if orders were not written and there is no standing protocol to address the omission wouldn't you consider that malpractice? I would!
To the nurses involved I want to say "Bravo for protecting your patient's from futher harm." I also must acknowledge that each of you should have known better. I will be deeply saddened if the choices you made are held against you. Having to stand before your Board of Nursing and accept a letter of reprimand be placed in your file would be one thing; any corrective action beyond that is overkill as far as I'm concerned. [/b]
There are many a good post trying to understand the position these nurses were put in and what consequences should have been, however, I think Granna said it best here. I also commend all the positive and supportive posters for not getting 'in the dirt' with the negative posters who want to judge so easily and even to the incredibly ignorant level of calling these nurses stupid.
1) WALK A MILE in another's shoes before you judge (remember? we dont even have many of the facts here, and there is always more to a situation than meets the eye)
2) Hindsight is always 20/20.... of course it makes you feel smart to know what these nurses 'should' have done...
3)I believe 99% of nurses are only trying to do whats best for the pt so why are we so harsh with each other when we make mistakes? I believe in acknowledging such and learning from it but pointing the finger and calling someone stupid and 'shoulda, coulda, woulda' is only demoralizing which helps no one.
There's one fat reason for the nursing shortage.
Also in response to PsychRN statement of:
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.
PsychRN,
That is the FIRST thing I thought of when I read the article. Yes, VERY ODD that something wasnt ordered for the vent pts and supposedly for so long. It is quite obvious that this system is quite dysfunctional in many ways. I find it especially disgruntling that the nurses seemingly had no avenue to file grievances against these doctors or management... what a screwed up mess. But hey, the pts are ok. For now....
Senior nursing student here--seems like there are two issues: administering meds without an order (legal) and medicating patients for the convenience of the nurses (who didn't want the docs' wrath or whatever) (patient care).
In my externship I never saw anything like this in the ICU where I worked (with plenty of respirator and central line patients with AMS who could hurt themselves if they began pulling at tubes, pipes and lines)--but I did see this sort of mistreatment of patients NOT ON RESPIRATORS on med/surg floors I floated to.
In those cases, the nurses would ask for conditional orders from the docs--a sedative would be ordered prn agitation or some such, then the nurse would "document" that the patient was agitated (a 90 year old patient who wanted to walk to the bathroom during shift change sometimes "became agitated")--this happened most often with elderly but active (and therefore time consuming) patients, in effect penalizing them for the very parts of their personalities and physical health that probably kept them up and active into their dotage.
I am surprised that the KY hospital got paid for the Diprivan, and that this behavior wasn't caught and stopped earlier UNLESS the nurses were documenting VO's and the docs were OK'ing them after the fact (verbalized or not), since QC staff (not to mention HMO's) are really onto watching for this sort of thing.
Isn't it kind of basic not to give meds that are not ordered? I mean, we covered this the first week of school....
Personally, I would rather have someone holding my hands and talking to me while waiting for the actual VO, than to have a nurse (and I've worked with some really wonderful ones) administer meds without my doctor's knowing about it. And for the money those docs are making, they can jolly well wake up if they didn't order prns! But then, I also want a tattoo on the back of my throat that says, "DO NOT INTUBATE."
Specializes in Trauma,ER,CCU/OHU/Nsg Ed/Nsg Research.
Originally posted by Rhon1991
1) WALK A MILE in another's shoes before you judge (remember? we dont even have many of the facts here, and there is always more to a situation than meets the eye)
2) Hindsight is always 20/20.... of course it makes you feel smart to know what these nurses 'should' have done...
3)I believe 99% of nurses are only trying to do whats best for the pt so why are we so harsh with each other when we make mistakes? I believe in acknowledging such and learning from it but pointing the finger and calling someone stupid and 'shoulda, coulda, woulda' is only demoralizing which helps no one.
You don't have an order, you can't give the med. You must chart all meds that you give. That's Nursing 101. If the unit has standing orders, they need to be signed and on the MARs.
If I read this correctly, only night RNs were fired? I don't buy that this only happened on nights- patients hate their tubes 24/7. It's cruel to have an intubated person unsedated. Continuous is nice, prn is fine. I think it's poor medicine to not order sedation. It's poor nursing care not to ask for orders if it's overlooked. If the doc says no, chart it and go over his head if necessary. You can't just give whatever you want.
I can see this situation happening- ONCE. The one time I had to hold a patient down while someone stat paged a doc for orders would be the last time. After that, I would ask what the patient has ordered for sedation while in report. If the answer was "nothing", then the doc gets paged right then.
For this situation to happen once is the doc's fault for not writing proper orders. But this situation happened with many patients, many nurses, and presumably multiple docs? That's a much MUCH bigger problem.
The nurses may have been coerced by unit routine into making bad decisions and administering meds illegally. But they still did it and are responsible for their actions. Only nurses trying to start a union may have been fired- that doesn't change the fact that they gave meds without orders. Just tells me other nurses need to be fired too, not that these didn't deserve it.
Sorry to sound unsupportive. But "everyone does it" doesn't cut it with me. I'll be happy to retract my criticism when the facts come out if I am wrong.
ratchit writes: "The nurses may have been coerced by unit routine into making bad decisions and administering meds illegally. But they still did it and are responsible for their actions."
This is an excellent reminder of the simple fact that once you break the rules (or the law) in order to "be a team player," or "not make waves," or "to fit in," your employer and supervisors have you over a barrel about everything you might do, not do, want to do, or want not do in the workplace. You have surrendered your right to any workplace choices (assignments, time off, forming a union, etc.) without having to pay the price of your infraction's being revealed and potentially punished.
It is, quite simply, blackmail, but you entered the bargain willingly. You sold out your professional, and perhaps personal, principles. Now you play THEIR game or YOU get in trouble.
I agree with some of the posts..this was probably a long standing practice that no one thought about getting a standing order for. The nurses said they would rather give the Dipravan than wake up a doctor. There's definitely something wrong with that picture. An institution which allows fear of retaliation from physicians just because they are awakened at night just is not right. The leadership at that hospital should take a long hard look at why this was happening. To terminate the nurses and perhaps ruin careers and livelihoods is madness. My prayers are with all those nurses. There's not one of us who have worked nights with rowdy patients who haven't used a standing order for sedative or called the physician. I, for one, call the physician whether he likes it or not.
Granna
2 Posts
However, it seems to me that now is the time to call in the BIG GUNS to look into the overall practices in that hospital. There is no way management was unaware of what was going on. There is no way the doctors were unaware of the common practice nor is it possible that the doctors did not condone the common practice. Leadership comes from the top. Apparently the leadership at this facility saw no reason to question or correct the comon practice until it was recognized as a means of punishing those experienced nurses for speaking/acting to protect patients by advocating for a union. thr Big Guns that need to be called in to do a full and complete investigation are; Kentucky Dept. of Health, JACHO, Center for Medicare and Medicaid, The State Nursing Association as well as the Board of Nursing, Federal Labor Relations Board and any Association that certifies the specialty practice of nursing on the nursing units involved.
While I do not condone practicing outside of your license, I do know from experience that there are times that a nurse must take an action in order to protect a patient or risk an undesired outcome that could include serious harm or death.
I also believe that the State Medical Board should be initiating active and in depth reviews of the medical practices of any physician involved in this case. After all, if orders were not written and there is no standing protocol to address the omission wouldn't you consider that malpractice? I would!
To the nurses involved I want to say "Bravo for protecting your patient's from futher harm." I also must acknowledge that each of you should have known better. I will be deeply saddened if the choices you made are held against you. Having to stand before your Board of Nursing and accept a letter of reprimand be placed in your file would be one thing; any corrective action beyond that is overkill as far as I'm concerned.