Trying to Cool My Jets

  1. Dear Nurse Beth,

    Trying to cool my jets so will bounce this off some of you fellow Nurses.

    I am a RN working in primary care clinic as part of a larger hospital system. I have 20+ years of experience and have worked ER/ICU most of my career. Have been working primary care to slow down a little prior to retirement.

    One of my duties is close management of our diabetic patients. I call patient and record their Blood Glucose readings as they tell me or sometimes they will fax or email to me. I then discuss with the doctor I work with. (Her desk faces mine in same room). She will tell me what changes she wishes to make to patient's insulin dosing and I will call patient back and relay that information to them and make sure they understand. (Sometimes when I have patient on phone I will discuss with doc and give the instructions right then. I then enter what I told patient in electronic chart and send note to doctor to counter sign. A couple of days ago someone in QAI decided that I was titrating insulin without a protocol and recommended disciplinary action on me.

    Now my manager is on the same band wagon. Really??? I am not giving the insulin. I am merely passing along information to the patient that doctor told me to and documenting. Am I losing it or is this a little extreme by QAI person. I have never been disciplined for anything in all my life as a professional.

    Dear Cool My Jets,

    This sounds like a practice based on provider convenience more than anything.

    The most important thing is to follow your facility's procedure. It does not seem likely that a facility would have a written procedure to manage insulin dosing such as you describe.
    The process is overly casual with no safety checks. It's possible to see where the order could get lost in translation and errors could occur.

    What is the policy on taking a verbal order? Is there a read back requirement? Is there a reason the doctor does not enter the prescription change herself??

    No one is judging your expertise, it's the process that is problematic.

    Your manager should make it perfectly clear what is expected of you, and not leave you out on a limb. It's not helpful to blame you and not give clear instructions. Likewise, the doctor should follow procedure.

    Think about how you would feel if a patient overdosed on insulin and the doctor had not yet countersigned your "note", or even refused to sign, claiming it was not the dose they prescribed.

    Maybe once you see this in a new light, you'll be glad this happened so you can protect your license.

    Best wishes,

    Nurse Beth
    Author, "Your Last Nursing Class: How to Land Your First Nursing Job"...and your next!
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    About Nurse Beth, MSN, RN

    Joined: Mar '07; Posts: 1,534; Likes: 4,543
    Nursing Professional Development Specialist; from CA , US
    Specialty: Med Surg, Tele, ICU, Ortho

    5 Comments

  3. by   Wuzzie
    TJC has brought the hammer down on verbal orders which is fundamentally what you are receiving. However, you are not documenting them in the way that is traditionally acceptable. This could (and apparently has) get you into trouble. This system definitely works to the convenience of the physician but now you see why it is problematic for you. We had this issue on our triage lines. There are two areas where documentation can be done. Progress notes and routing comments. Routing comments are not part of the view-able chart. Our physicians were constantly responding via routing comments and we had to work very hard to get them to respond via the notes so there was actual documentation of what they wanted. All that being said I don't know why they think this should be a disciplinary thing. This is a process issue not your intentional wrong-doing. Your manager should have been aware of how things were being done and if she was aware she's throwing you under the bus. If she wasn't aware then perhaps she needs to get a better handle on the clinic she's supposedly in charge of.
  4. by   llg
    Yeah ... the way you are currently doing it is inappropriate and not in line with current standards -- but that is something that should have been rectified in your clinic a long time ago. The system should have been changed a couple of years ago and you should have been taught correctly by whoever oriented you to your current job. Though maybe those standards are only just now reaching out-patient departments. They've been around for years in inpatient care.

    The bottom line is that verbal orders are not supposed to be used except when absolutely necessary (e.g. emergency situation). It's not your fault that your employer didn't keep their processes up-to-date and consistent with evolving standards. I think it is wrong to discipline you for their mistake.
  5. by   UC nurse
    Unfortunately, accepting verbal medication orders in the outpatient setting is very wishy-washy. As LLG posted, it's against policy and procedure (except for emergency situations) and the supervisors know this. They don't want to create waves with providers so they do not enforce the policy. If RNs in the clinic refused to enter verbal orders, they would be out of a job. As far as I know, TJC doesn't set foot in our clinic.
  6. by   Nurse Beth
    Quote from UC nurse
    Unfortunately, accepting verbal medication orders in the outpatient setting is very wishy-washy. As LLG posted, it's against policy and procedure (except for emergency situations) and the supervisors know this. They don't want to create waves with providers so they do not enforce the policy. If RNs in the clinic refused to enter verbal orders, they would be out of a job. As far as I know, TJC doesn't set foot in our clinic.
    Good point, and if Medicare insurance is accepted, then the clinic is held to CMS regulations. CMS does not allow verbal orders except in emergencies or when it would break a sterile field. Then again, my background is acute care, and not outpatient.
  7. by   NurseDiane
    Well then, what is the "policy" as far as insulin titration? Unless the practice can produce proof of a policy that you were not following, I can't see how they can throw you under the bus. Plus, the doctor wasn't following "the policy" either. If they are going to throw you under the bus, they're going to have to throw the doctor under the bus too.

    If they can, and do, produce a "policy", make sure you see a date on it. If the QI person identified an area of concern, the process should have been a manager speaking to you about it so you could change it. Plus, the doctor also needed to be notified of this so they could change how they were practicing. If you didn't know you were doing anything wrong, you certainly aren't going to do it a different way.

    Also---who was the person that taught you to do it this way?

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