So we started a new computer system about 2 weeks ago, which has had a MAJOR impact on patient care. NOw, there is no paper charting at all, and all orders go through the computer, and documentation on such orders is also done in the computer. Now, of course, the nurses all went to training even on how to input orders for the providers, because of course, they could not be madated to learn the new system. Which has also caused quite a commotion with patient care. (I work in Urgent Care)
I have been at the same location for over 2 years now, and have worked with one provider in particular for those 2 years. Never had an issue, not one. Never been written up, never have had a coaching or even a 1:1. Never had even had a med error/procedure mistake.
That is, until this new system came in...
"Mistake" #1
Provider puts in an order for a CT scan. Order reads exactly: CT w/contrast.
In our job, unless otherwise annotated or commented on, CT w/ contrast is always oral.
So, of course, I gave the patient their cups, and they complete 2/3 contrast drinks. I annotated in the chart, and put a flashing comment for the provider to see on their computer screen, that stated "CT with oral contrast started 1400"
Around 1630 I am notified by CT that the doctor has inquired to him just now why did the patient get oral contrast. Of course, I inform the Doctor that unless otherwise specified, ct w/contrast is always oral. Doctor wanted IV. When I inform the doctor that he put the wrong order in, of course I was given the 3rd degree on how I am supposed to be a mind reader and just "know" that he wanted IV, even thought I told him he must put in the administration instructions or at least an annotation that says IV contrast only, which he did not.
I file an incident report, no harm done. Lady had better kidney function that I did so there wasn't anything to worry about. Management sided with me of course after reviewing the order, and the fact that there was a bold faced comment of the time I started the 'oral contrast' that the provider neglected to acknowledge. Management informed him that had he gone to the training, he would have known which order to place, and I was not at fault by any means.
"Mistake" #2
About 2 weeks pass since the contrast incident. Now, the doctor orders routine blood and chem orders for a pt with abd pain. Blood is ran, easy draw without complications. Blood shows a potassium level of 5.1, while other numbers were in range. Per my charge nurse, I was instructed to re-run the same blood, because had it been heamalyzed, she stated other values would be off. So I ran the same blood. Again, potassium level is 5.1is to 5.2 without other abdnormal ranges.
Provider comes to me and asks why there are 2 ranges, and I inform him that per charge, I was instructed to re-run the same blood. He orders me to draw new blood just to triple check. I use a different arm, easily draw a second sample and run it. Strangely though this potassium level is 4.3 without nothing else out of range. I inform my charge nurse. I also PRINTED a copy of the latest 4.3 result, and give it to the doctor who acknowledges I gave it to him.
20 mins go by and here sed doctor comes stomping from the office demanding to know which potassium level is correct. I let him know the 4.3 level is the latests, and he was given a copy of it, which he took from my hands himself.
He had treated the patient based off of the 5.1 range, and again, blamed me for his carelessness.
My charge nurse was by my side, and told him to be more careful and that it was not my fault, as she witnessed me give him the new blood results.
Now, this jerk off has threatened to report me hahahaha....
What a day...
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BeenThere2012, ASN, RN
863 Posts
You are correct. I fell down the same hole in discussing the lab issues. I was trying to discern what the complaint was about and then when you see people having questions on a "how to", you feel compelled to give correct information or dispute the incorrect.