Policy/Procedures or DON rules?

Specialties Geriatric

Published

Had my first med error today :( When I looked at the front page on the chart, it listed NKDA for the patient. Dr. ordered Bactrim. After giving first dose, I noticed the pt was allergic to sulfa. This was within 1 hour of the dose. Patient had no adverse reactions, normal vital signs. Notified Dr and Family, they were unconcerned, but Dr changed order to cipro.

I went to tell my DON about the mistake, and she told me that the nursing staff needed to follow up for the next 24 hours by assessing and charting every 30 MINUTES!! Are you kidding me!?!?! I checked the policy/procedure book and it said to do initial assessment, then follow up q shift for 3 days. This seems much more realistic.

However, does the DON's rule override the policy/procedure book?? This DON is famous for piling on tons of unnecessary work that is not in the procedure guide.

What should I do? I dont want to get in trouble with the DON, but I really feel she is being excessive :(

Advice??

eta: discovered allergy because allergy list in chart did not match allergy list in MAR.

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Specializes in acute/critical care.

Silly, silly, silly.

Some perspective -- lots of patients get desensitized to allergens in a clinic setting. They get injected with (small amounts of) substances they have a known allergy to. They have to sit in the waiting room for 1/2 hour to an hour to make sure they don't have any type of anaphylactic reaction. If they don't, they hop in their car and go home. There is no q30 minute monitoring at home.

Your patient took an oral medication that he was (supposedly) allergic to. Nothing happened. So you have to assess him q30 minutes for what? If the DON was that worried and she thought the patient needed that much monitoring, doesn't that meet discharge criteria in most LTCs -- like, call the ambulance and get him on the way to the ER?

Does your allergy list what the reaction in the past specifically was? This is generally the standard these days. If it was "diarrhea" or something like that, I don't know why that would warrant a q30min assessment.

Sometimes patients have delayed reactions to antibiotics, but they are usually in the form of a non-life threatening rash. The guy got one pill, not repeated doses.

I would go with your P&P, but I don't know how you are going to get around what your DON wants. Also IMO if she wanted you to "assess and chart" q30 minutes, what does that mean? A set of VS? A head-to-toe? A visualization (e.g. go check on patient, make sure he is not in any distress?)

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I believe the DON was referring to at minimum a skin assessment and pulmonary assessment.

When I spoke to the family after the incident, I talked to the patients daughter-in-law, and she said she was unaware of the allergy, or any previous sulfa reactions. She had been caring for the patient for the past 10 years.

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Specializes in Hospice / Psych / RNAC.

Sure I disagree constantly but if everyone just went off and refused to do what the boss says it's going to create chaos. I agree it sounds over the top but what if something does happen? It will be you who will be in the very hot seat. Yes we do go buy hospital policy but if it's overridden by the DON directing a different procedure do we go with what policy says or the DON..... Hmmm that's the question.

Look at yourself in court telling the jury that you decided to go against what your DON told you to do and went with a written policy. Hmmm I don't know. There's a time and place for everything. Start proceedings against the DON for what ever it is you want changed but until you do I would follow what she directs IMO.

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Specializes in LTC, Hospice, Case Management.

Just remember the P&P book can not fire you. The DON can.

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Specializes in Developmental Disabilites,.

wow. It sounds like she was trying to punish you.

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Specializes in Med/Surg.

One should never do ANYTHING just because someone said so: You can question your DON & make her aware of the P&P..i.e. I just wanted clarification. The DON doesn't have the authority or the right to "make her own policies" and if you're in court I tend to believe a written policy is going to carry more weight. Turn it around: what if the policy said assess q 30min x 4 hrs & your DON said "oh you can assess every 1 hr for 4 hrs" what do you do then? No question you follow P&P because that's what it's there for. Bottom line: speak with your DON, question her reasoning and have her be very specific on what she wants documented...if she insists on every 30 min..so do it this time..but follow up with her boss. Because if this happens again to another pt, who does have a severe rxn, & it were to go to court, and the DON didn't consistently follow P&P, then there could be problems

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Specializes in Gerontology, Med surg, Home Health.

So glad the resident is okay. Let's start with him/her. If it's not a true allergy...you know the 'allergies' people list because the medication made them queasy...then get it off the allergy list. If it IS a true allergy, make sure you let your pharmacy know.

I've worked for DONs and ADONs who make up the policies as they go along. At one place there was the P&P book and then the DON/ADON rules. If they liked you, there were no extra rules. If you questioned anything, all of a sudden there was a rule or procedure or something. We had a code one day. The other nurse on the floor and I took care of it, did what we had to do, and got the man out to the hospital. He survived. I got called into the office the next day because I didn't page the ADON or DON overhead. When I brought out the Policy about codes, I was told "Everyone knows you're supposed to call us." Hmmmm....show me where this is written. If the DPH comes in, I can't tell them "Here is the policy, but everyone knows it's up to the DON." Mind you neither of these 2 charmers had taken care of a real person in years and the ADON didn't even know how to crack a tank of portable 02.

There are plenty of crazies in this business who thinks more is better. More might get you in trouble some day. In a different building we had a P&P for neuro checks after a fall....q5 minutes for the first 4 hours, then q15 for the next 4, then q30x72 hours! The neurologist who made rounds thought it was preposterous and told the DON that she should change the policy to keep it in line with the standard of practice.

If someone gets a medication to which they have a true allergy, I would assess them every few hours for the first shift.

But as someone else here said....the P&P can't fire you.

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Specializes in Geriatrics.

But if you're fired because you followed P&P.... wouldn't there be a write up the DON would make? Then you take write up and compare it to P&P and just sue for wrongful termination. lol

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But if you're fired because you followed P&P.... wouldn't there be a write up the DON would make? Then you take write up and compare it to P&P and just sue for wrongful termination. lol

If you are in a "right to work" state good luck with that.

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But if you're fired because you followed P&P.... wouldn't there be a write up the DON would make? Then you take write up and compare it to P&P and just sue for wrongful termination. lol

Wrongful termination refers to an employer either violating the employee/employer contract or breaking one or more State or Federal labor laws. Can almost 100% be certain there is some sort of "Employ at will" clause within her contract (if she read it).

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The DON hired you, she can fire you. The DON decides what is policy, that is one of her basic roles within the facility. It would be prudent to follow what she says.

BESIDES.

You always follow safest practice. Checking your patient every 30minutes is not a HUGE request. If you were before the Board or a Jury would you really whine that you did not want to check your patient every 30 minutes? I would be very surprised your DON ment a full head-to-toe assessment and a full paragraph in the chart every 30 minutes.

A flow sheet checked off every 30 minutes or charting stating res continues on q30 minute wellness checks should suffice.

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