Physician Giving Sedation Without Nurse

[Udmert]

Looking for opinions on a situation. Recently had a physician take a controlled substance off of a nurses computer, and give it for a conscious sedation without the nurse knowing. Physician never notified RN and patient did not have any safety precautions set up for the sedation. Has anyone else ever had an issue with a physician taking controlled substances from them without their knowledge and giving them without following conscious sedation protocols? Patient should’ve been a 1:1 but RN was not made aware the sedation was being started. Any advice on what to do other than escalating up to management? This is the kind of stuff that puts our licenses at risk and the patients life at risk.

I should add that this is in an ER setting on a low acuity area of the ER where the RN already has 11 other patients at a time

[canoehead, BSN, RN]

That his problem if something goes wrong. I'd report it to management.

[ghillbert, MSN, NP]

Why was sedation sitting around unattended? I feel the nurse made the error there. 

 

[Udmert]

21 hours ago, ghillbert said:

Why was sedation sitting around unattended? I feel the nurse made the error there. 

Sedation was in the unopened vial on the nurses computer. While the nurse was with another patient the physician took it off the computer.  Although medication should not have been sitting around unattended, physician should not have pushed sedation with no other staff at bedside and leave the patient unattended not notifying the nurse. At our hospital since the procedure was a conscious sedation there must be a 1:1 nurse with that patient until the patient is awake. The biggest issue here is a physician taking a medication from a nurses computer and giving it while leaving the patient alone after the procedure never notifying the nurse.

[chare]

2 hours ago, Udmert said:

Sedation was in the unopened vial on the nurses computer. While the nurse was with another patient the physician took it off the computer. ...

And this is a problem.  If the nurse that removed the medication had properly secured it, the physician couldn't have taken it.  

2 hours ago, Udmert said:

... At our hospital since the procedure was a conscious sedation there must be a 1:1 nurse with that patient until the patient is awake. ...

If this was a conscious sedation, and the provider failed to follow established procedures and placed the patient at risk, her or his unsafe practice should have been reported.

2 hours ago, Udmert said:

... The biggest issue here is a physician taking a medication from a nurses computer and giving it while leaving the patient alone after the procedure never notifying the nurse.

No, it isn't.  The biggest issue here is the nurse removing controlled substances and leaving them unattended.  Ideally, the nurse in question should not have removed the medications until they had been ordered and he or she was ready to administer them.  Had he or she done so, and kept them secured, none of this would have happened.

[JKL33]

Agree with those above. The biggest issue is the unattended CS. Terrible practice and an excellent way to get completely burned. The entire hospital culture around CSs has been very cautious and also very heavy-handed for quite some time now that there's just no defense of this action and you won't find many people to even try to understand it.

However. I will bet that there is some component of poor culture and unreasonable expectations involved. People do things like that because of pressures and not enough help; they know they need to be prepared when it's time to go but nothing else about the place is set up for them to actually be prepared and ready to go. I feel for you with that, on the other hand it's the same reason the doc probably took the med and started the procedure.

The whole thing sounds like a circus.

Your job in these kinds of circumstances is to do what is right  and what is safe and let the chips fall where they may.

People are going to be upset if you are not 100% ready to go at exactly the right instant, sure. OH WELL. There is a lot more that needs to change than just what 1 RN happens to be doing at that given moment, if management wants a smoothly running place. **If management chooses not to participate in facilitating a smoothly running ED, that doesn't mean that YOU start taking shortcuts to make up for their refusal.**

 

[Hoosier_RN, MSN]

On 7/24/2022 at 11:48 AM, ghillbert said:

Why was sedation sitting around unattended? I feel the nurse made the error there. 

 

My thought as well. The rest is bad, but the way this is worded, this nurse was open for this mistake, and has probably just learned a very valuable lesson. Unfortunately, it could lead to job loss, up to possible license revocation (not securing a controlled substance), and everything in between

 

[Hoosier_RN, MSN]

6 minutes ago, JKL33 said:

Agree with those above. The biggest issue is the unattended CS. Terrible practice and an excellent way to get completely burned. The entire hospital culture around CSs has been very cautious and also very heavy-handed for quite some time now that there's just no defense of this action and you won't find many people to even try to understand it.

However. I will bet that there is some component of poor culture and unreasonable expectations involved. People do things like that because of pressures and not enough help; they know they need to be prepared when it's time to go but nothing else about the place is set up for them to actually be prepared and ready to go. I feel for you with that, on the other hand it's the same reason the doc probably took the med and started the procedure.

The whole thing sounds like a circus.

Your job in these kinds of circumstances is to do what is right  and what is safe and let the chips fall where they may.

People are going to be upset if you are not 100% ready to go at exactly the right instant, sure. OH WELL. There is a lot more that needs to change than just what 1 RN happens to be doing at that given moment, if management wants a smoothly running place. **If management chooses not to participate in facilitating a smoothly running ED, that doesn't mean that YOU start taking shortcuts to make up for their refusal.**

 

100% this!

[JKL33]

Sorry, I have more to say ?

I want to lay out the thinking here because I have seen countless nurses succumb to ED pressures which are mostly related to volumes, staffing and overall feeling helpless.

There are real emergencies. These are the ones where a patient's outcome is going to be affected by a smooth, rapid intervention (or the lack of timely intervention).

Then there are management's "emergencies." Otherwise known as their business-related fantasies, which they think others should be able to magically perform.

Was the situation in the OP an emergency? No, it wasn't. We know that because if you were working in a low acuity area and this "emergency" ended up there, you would have been at that bedside, instead of having time to go get a med from the pyxis and put it on top of your computer for use sometime in the future, with time left to go do something else.  You can check my assertion by asking yourself what was the accurate ESI of the patient we're talking about. I am guessing it wasn't 1  and it wasn't 2.

This is important because so many nurses feel this pressure and respond by taking actions that put themselves or patients at some kind of risk. And for what?? Mostly so that someone doesn't throw a toddler tantrum somewhere down the line because their fantasy was not delivered. 

The risks being taken here are significant; top 3 off the top of my head:

- Other team member takes the med you pulled and uses it in a way that harms a patient

- Medication swiped by random passer-by for their personal use

- You are accused of inappropriate handling of controlled substance

Now ask yourself whether the patient scenario for which you pre-pulled this med is "worth" all of those risks. In my book the answer is no, because very little, almost nothing, is worth those risks to MYSELF/YOURSELF and others.

If management, the doc, the patient, the family, your coworkers, whoever, does not like that opinion, they can all go suck lemons.

The above thought process is something that I wish all nurses, whether new or experienced, would really take some time to ponder. Do NOT put patients or yourself at any kind of risk. If a workaround it necessary for a really worthy reason, you must come up with one that preserves everyone's safety (including physical safety and legal/disciplinary safety).

Management's expectations are not, independently, emergencies worth risking anything.

[sleepwalker, MSN, NP]

22 hours ago, JKL33 said:

Management's expectations are not, independently, emergencies worth risking anything.

Exactly. And you can bet management will not support the nurse when/if something goes wrong...then nurse will just become the scapegoat for management issues/problems

[ghillbert, MSN, NP]

On 7/24/2022 at 1:52 PM, Udmert said:

Sedation was in the unopened vial on the nurses computer. While the nurse was with another patient the physician took it off the computer.  Although medication should not have been sitting around unattended, physician should not have pushed sedation with no other staff at bedside and leave the patient unattended not notifying the nurse. At our hospital since the procedure was a conscious sedation there must be a 1:1 nurse with that patient until the patient is awake. The biggest issue here is a physician taking a medication from a nurses computer and giving it while leaving the patient alone after the procedure never notifying the nurse.

I disagree. Nurses can't control physicians. They can control the substances they remove from secure storage and leave on their computer. If it wasn't there, it wouldn't have happened. The nurse's job is to safeguard the patient by following procedures and protocols. Leaving drugs unsecured is not the way to do that. 

[LubbDubb77, BSN, RN]

The whole scenario is terrible. Don't leave any medications unattended, EVER. Just don't do it. I would have spoke with that physician directly about this and wrote them up. Honestly, the nurse should be written up for leaving that med out. Multiple errors and lack in judgement here. 

So many people pass by my desk at the nurses station. I just can't imagine how horrified I would be if I came back to my desk and that medication was gone.