Orders from hell...

[Leonardo Del Toro]

From time to time I run into real gems of medical writing.

Levaquin 750 gm P.O. q. 48 hours for 2 more days

the trick is to find how many pills this will be

Can you?

[Kooky Korky, BSN, RN]

Oh, I just remembered a great one. We had a patient on an uncommon specialty drug for an off label indication that had to come from a far away pharmacy and was exorbitantly expensive. The patient was dying and made a miraculous turn around on said med. We'll call this guy Patient A. At the same time Patient A was admitted, Patient B came in with the same condition under the same service. The physician immediately began trying to get approval to get Miracluzamab for Patient B but it was looking like it would take awhile.

So he wrote an order "Please give one of Patient A's Miracluzamab pills to Patient B daily. We'll replace them when Patient B's supply comes in." Yep. So Patient A's name was actually in Patient B's chart.

Incidentally, this was the same physician as the aforementioned highly inclusive Ativan order.

Sounds like he needed some Ativan. LOL

[Kooky Korky, BSN, RN]

Can't believe I haven't thought of mention this 'til now. Several of us have talked about a ridiculously-explicit and insulting order from a wound care clinic. It says, among other things, to wash hands, use sterile gauze (when cleaning the wound) instead of cotton balls or unsterile gauze, and to not use pressure when cleaning the wound. Really? I would have had no idea about any of that, right? I feel like asking them if I can use one of those old faded-red mechanic's rags when I'm cleaning the resident's wound.

You'd be amazed how even surgeons don't use sterile technique on their postop dressing changes. Took my loved one to surgeon for first postop visit. First, the assistant took off the dressing with scissors that were likely used on 50million other patients,without so much as being wiped down by alcohol between patients.

She then was going to take out stitches, until we reminded her that it had only been a week since they were placed and asked her to check with doctor first. It was bad enough she insisted on removing the steri strips without checking.

Then he comes in, checks wound using clean (not sterile) gloves, doesn't wipe it with anything, and proceeds to dress it with clean gauze. He had used his gloved hand to adjust the location of his stool before putting the gauze on the wound. If loved one doesn't get infection, it will only be because of my prayers.

So orders to chart VS, I&O, etc., orders to bathe, are not far-fetched at all. The orders you got were likely written by a doctor who has seen it all and wants to ward off wrong behaviors, not personally directed at you.

[Kooky Korky, BSN, RN]

My aunt's nursing school text from 1945 has a chapter devoted to flower arranging and care. We've come a long way baby.

Had a patient with SBP in the 80's and a full code. The doc's order was to stop taking vital signs. (and stop calling him in the middle of the night)

Flower care would be more fun.

[Kooky Korky, BSN, RN]

My favorite is from nursing school, back in the 80's... Transderm Nitro p.o. Q am. Transferred to the MAR by staff for the last two weeks... they told me "just put it on him, we know that's not the way to give it." Great way to teach a student. I got bonus points for catching it, tho.

I can just see it... "here, mr. x, just chew on this for a while."

This is the stuff that irritates and scares me. No one can be bothered to get the order corrected. I know we are all busy, but didn't anyone see the doctor and get him to correct it?

How come Pharmacy didn't pick up on it?

[Rose_Queen, BSN, MSN, RN]

Sounds good, but then everyone would get addicted to going to work....Literally!

But think of the sudden decline in absenteeism! No more people calling off for their shifts! Happy employees! And happy employees are productive employees!

[SteffaDee, BSN, RN]

I'm sorry, but what is a "tappered" dose?

I believe its supposed to be "tapered" dose, which is when the dose gradually decreases until they are no longer taking the medication (ie. Prednisone 50mg PO Daily x3 days, then 40mg x3 days, then 30mg x2 days, etc.).

[angeloublue22, BSN, RN]

I had a doctor order smoke breaks for a COPD client. I had to have long conversation with him about what can be prescribed.

[IsabelK]

An ECG to diagnose death, eh. And he didn't make you prove that the leads hadn't fallen off?

No, thank god....but we also made sure to print the tele strip for the same timeframe...lol. By the way, he never did that again....

[IsabelK]

Wow! From where do they get their nurses and CNA's ?

Not sure...but it's endemic in some of the nursing homes. I would hazard a guess and say "none of the schools I attended" because all my instructors would have killed anyone who didn't get vitals and record them....

[IsabelK]

I had a doctor order smoke breaks for a COPD client. I had to have long conversation with him about what can be prescribed.

Actually, it is a legitimate order in some of the LTCs I work in where smoking is still allowed for some of the residents. Do I agree? Nope, but I also feel like if you're talking about someone in his or her 80s or 90s and this is one of their few pleasures in life, I provide the education and then write safety orders. Family or friends have to provide the cigarettes and the facility has designated smoking monitors and times. I know of at least a few folks in each of those buildings who like being the smoke monitor because they go out and smoke, too.

Most of the buildings, though, are smoke-free now which I like much better.

I also write orders for alcohol for the intermittent resident as long as the family or friends provide it.

[Cruella de ville]

I get one-time-only orders from one doctor for 6u Novolog for someone who's 600+ blood glucose. (Our stupid glucometers, even though they have 3 digits, don't go to '999' - if it's above 599, it just says "HI" - yes, some engineer should be drawn & quartered. Because if it says "HI", you have no idea if they're 601 or 851. Regardless, 6 units ain't gonna do much.)

The machines are only calibrated to be accurate up to a certain number so a 599 could be 601 or 899.

Even the low numbers are only accurate down to a certain number and so anything under or above the parameters set by the manufacturer needs to be confirmed by a lab draw.

6u won't help any blood sugar that high. 😃

[3ringnursing, BSN]

You'd be amazed how even surgeons don't use sterile technique on their postop dressing changes. Took my loved one to surgeon for first postop visit. First, the assistant took off the dressing with scissors that were likely used on 50million other patients,without so much as being wiped down by alcohol between patients.

She then was going to take out stitches, until we reminded her that it had only been a week since they were placed and asked her to check with doctor first. It was bad enough she insisted on removing the steri strips without checking.

Then he comes in, checks wound using clean (not sterile) gloves, doesn't wipe it with anything, and proceeds to dress it with clean gauze. He had used his gloved hand to adjust the location of his stool before putting the gauze on the wound. If loved one doesn't get infection, it will only be because of my prayers.

So orders to chart VS, I&O, etc., orders to bathe, are not far-fetched at all. The orders you got were likely written by a doctor who has seen it all and wants to ward off wrong behaviors, not personally directed at you.

I worked with a CT surgeon who always whipped out his own nasty looking scissors to remove chest tubes. I'd always pad down the bed and the floor with chucks, and lay a sterile suture removal kit next to it. When he was ready I'd peel back the top and leave it near him … he'd always ignore it, pull out his funk covered scissors from his lab coat pocket, snip, snip - yank out the chest tube (insert patient screaming here) blood flying, and fling it to a section of floor without any chucks. Zip - he'd pull the sutures closed like purse strings (the patient still yelling in agony, trying desperately to find themselves through the haze of pain) spin on his heel and walk out - leaving me to comfort a writhing patient, and a nasty mess to clean up while cursing under my breath.

One day he left his fancy surgery telescope glasses sitting on the counter and left … I tried them on, played with them a bit, then ran a saliva covered finger down each lenses before putting them snuggly back into the padded case. Let him chew on that for a while as he obsessively polished them while wondering what happened to them.