Nurses not following doctors orders

TazziRN, RN · Aug 31, 2007

Then those nurses need to be reported, plain and simple. What do the docs say when they find out the orders weren't carried out?

Dolce, RN · Aug 31, 2007

That's my pet peeve, too. Usually when I reveiw the chart after receiving my patient I take note of current orders and it amazes me how many of them are not followed. Common ones are patients who have admission orders for SCDs or ted hose and 3 or 4 days into hospitalization they still don't have them on. Or another one is a disregard for activity orders. I really hate it when one shift has an order to do something and they fail to do it and don't report off on it to the oncoming shift. I had an incident last week where a patient had a >24 hour old order to DC the foley and the patient still had it in! I called the doc on that one and he wasn't very happy.

TheCommuter, BSN, RN · Aug 31, 2007

I think its unethical, unprofessional, and dangerous to just ignore a doc's properly-written order without talking to him about it.

I agree.

chloeysmom · Aug 31, 2007

I agree.

I also agree, we were trained to follow doctors orders, plain and simple. But what if it harms a patient? I sometimes question a doctors order (because I have been here forever, and I believe they trust me) if I think it will be harmful. Example, recently, a pt's bp was 86/53, when I came on and the doctor orders were cardizem at 5mg/hr. The previous nurse questioned him and he wanted it left on w/ a bp in the 80's, BUT in addition to this, her Heart Rate was 40's, I called and questioned it, and he said to d/c it. SO, I feel in some instances, you can question an order, but not in an insubordinate way.

dria · Aug 31, 2007

i think the op clearly excluded from this discussion orders that may poentially result in harm to the patient and was refrring to appropriate orders that are simply being ignored for no apparent reason...

fultzymom · Aug 31, 2007

Where I work if a docs order is found to not have been followed, we file an incident report et report it to the doc. Then track down who was there when the order was written, therefore responsible for it and find out why it was not done. IE: Did someone put the chart back before the nurse knew the doc wrote orders? Or were they just neglectful? Depending on what happened, we decide where to go from there.

We had a doc who was known for comming in, not communicating with the nurse, then putting charts back like he had never been there. I work in LTC and you don't usually know when docs will be in because generally ours does not keep a routine, execpt for our Medical Director who is in every Wednesday. Other than that it is whenever they feel like comming in. We had to get after him when we found out that some orders got missed because he was not telling us he had even been there. Also we now will notify other floors that he is here as soon as someone sees him to make sure it does not happen again.

queenjean · Aug 31, 2007

It sounds like your facility is letting this happen. This wouldn't happen long at my hospital; you can only be written up about something like that so many times before probation and termination occur.

Where's your risk management department? Why are the other nurses (I assume you are not the ONLY nurse in the entire hospital who thinks this isn't okay) tolerating this from their peers? Why are the docs tolerating it? What is your DON or department manager doing about it?

santhony44, MSN, RN, NP · Aug 31, 2007

These are things that need to be written up in incident reports, every time.

I can't believe your docs are tolerating this kind of thing. The places I've worked, they would've been pretty much demanding someone's head on a platter. In the cases you've cited, justifiably so.

Things like not doing daily weights on a CHF patient are not only ignoring correctly written doctor's orders, they are poor nursing practice.

bigsyis · Aug 31, 2007

These are things that need to be written up in incident reports, every time.
I can't believe your docs are tolerating this kind of thing. The places I've worked, they would've been pretty much demanding someone's head on a platter. In the cases you've cited, justifiably so.
Things like not doing daily weights on a CHF patient are not only ignoring correctly written doctor's orders, they are poor nursing practice.

Where I have worked, this would be exactly what would have happened. It is basically a form of insubordination-passively refusing to do what is asked of you. :uhoh3:

NurseguyFL · Aug 31, 2007

What do you mean by "a trend"? Exactly how many nurses in your hospital are doing these things---one, a few, all? Its difficult to believe that there is actually a 'trend' among nurses anywhere, to arbitrarily ignore doctors orders or protocols. Unless this is a hospital where the nursing care is generally sloppy, no one does quality control, no intervention from the risk management people, no clinical nurse specialists doing rounds with the staff, and the doctors themselves failing to follow up so as to demand to know why the tests they ordered weren't done, or why their post-surgical patients aren't wearing the SCDs, or what that CHFer's weight was done this morning. Sounds like there's plenty of blame to go around.

You also have to consider that some of these incidents aren't necessarily intentional, or even errors at all. Maybe the patient isn't wearing SCDs because the hospital either ran out of the 'boots' or there's no one in central supplies to bring the machine. I've seen both happen. Maybe the doctor filed the chart back on the rack after writing the order, then the patient went off the floor for a procedure with the chart and nurse missed the order. I've seen that happen, too. Maybe the order was called in as a verbal to the charge nurse and she forgot to write it down. Maybe that CBC wasn't drawn because the patient was off the floor in a precedure when the lab staff came to get the blood. Maybe the nurses didn't intentionally NOT do certain things but were so busy during the shift that they ran out of time to do it all before the shift ended.

Yes---a lot of maybes, but I have worked in places where all these things (and more) happened, and its not always the nurses' fault. But I've never seen it so bad that I would call it a trend. If this sort of stuff is commonplace where you are working then I'm surprised the manager hasn't done anything about it. Its difficult to believe that it could be as bad as you say and the manager is completely unaware of it. No staff meetings to discuss the problems? No write-ups for sloppy nursing care and serious mistakes???

One day something bad will happen, and when the lawyers come knocking everyone will held accountable.

queenjean · Aug 31, 2007

I will occasionally ignore a physician's order--and with this supposed "relationship based care" philosophy we are going to, I have that right. I just have to document my butt off to make sure I can back it up.

Example--SCDs and ted hose. Some of our docs order these on every pt. Well, that's just not appropriate. People who are walky-talky; people who are anxious and combative--they don't need SCDs and ted hose. It's a waste of time, resources, and money. I'm not going to put them on everyone; only people who actually meet the criteria for being at risk for DVTs.

Example--daily wts and I/Os. I'm not doing these on certain patients. It's not necessary. There are some situations for which this doesn't make sense.

Example--q4hour VS. Even if they are on tele or a PCA, I'm not necessarily waking someone up during the middle of the night to get their vitals. I check on them every hour, and I'll sure the heck wake them up if they are a new pt, or if they in any way are unstable--but if they've been there a while, have completely stable vital signs, and I just gave them a sleeper two hours ago, how does that make sense for me to wake them up to do vitals?

I *will* leave a note on the chart for the doc, explaining why some order wasn't followed, and asking them to clarify.