Published Jan 20, 2009
bark0093
4 Posts
I am new to this site, and have just finished my first year of nursing. but had some questions I was hoping someone could answer. I recently pulled a 3 way irrigation foleyl from a patient who had (i believe) uretal artery stents and a aortic aneurysm repair according to a electronic order in the chart. The foley had been in about 24 hrs and was still draining cherry urine. THe electronic order said to pull the foley POD1 at 0630 am. I felt like this may be wrong, so i spoke with a few colleagues and they all said that i could pull it if there were not clots, even though there was cherry urine. in my gut, i knew the order seemed incorrect, but i was nervous about not following the doctor's order. Our electronic orders are entered by a HUC and then checked by a nurse. This order had been red lined and checked by a previous nurse, so I did not think to go back into the chart and look at the original order. Low and behold, the doctor came in and flipped out because he had HAND WRITTEN on the original order set NOT to take out the foley. THis order had been overlooked by the HUC and the RN signing off the order. I spoke to the nurse following me that day and she explained the situation. I believe she put the 3 way foley back in with some discomfort from the patient.
I originally spoke with my manager the morning i found out hte issue with the order. I recieved a phone call today stating that i needed to come in and have another official meeting about this issue with possible corrective action???? Does anyone know what could possibly go wrong with my error to the point that corrective action would be an option????? ANY help and support would be great. I am freaking out.
NotReady4PrimeTime, RN
5 Articles; 7,358 Posts
It would appear that you're being forced to take responsibility for someone else's error. Your usual practice is for the HUC to transcribe the orders and an RN to verify them. The RN who verifies the transcription is supposed to be verifying that what is entered into the electronic orders is indeed what was ordered by the physician. Is it then the expectation that every single nurse who provides care for that patient is to go back all the way to the admission orders and make sure that every single subsequent electronic order is correct and complete? That would seem to be a waste of resources.
What you've learned from this is to trust your instincts. Next time you'll check the chart, or maybe discuss your concerns with your charge nurse and if you're still not sure, perhaps speaking directly with the doctor. There are times when it's preferable to question an order, no matter how routine it is, if the patient isn't following the care map. This would have been one of those times.
As for corrective action, don't assume that your head is on the chopping block. There was a system failure here and the management has no choice but to address the causes of it. So they have to ask a lot of questions and find out what part of their process has broken down in order to fix it. It may be that your practice will be adjusted so that at change of shift all orders written during the shift now ending are checked by both outgoing and oncoming nurses. That's how we do it on our unit; it's not perfect but it's better than relying on a single pair of eyes.
thanks for the quick reply. my manager did ask if we did chart audits on nights and as of right now, we have not been asked to. I am assuming that will change to prevent this problem. I am wondering if any adverse even could happen in terms of the renal arteries by me pulling the irrigation foley?? NO clots or excessive bleeding happened at the time, but I wonder???
What real effect will irrigating the bladder have on the renal arteries? Anatomically, they're quite a distance from the bladder. The purpose of the foley would be to provide an opportunity to observe what's happening inside the urinary tract from kidneys to urethra such as bleeding, and an accurate assessment of urine output, which is of course dependent on blood flow. Yes, replacing it was uncomfortable for the patient, since a three-way is a tad bit bigger than a one-way. But I seriously doubt that the patient suffered any other harm; you'd know about it by now.
has anyone had a "verbal or written warning" on their record??? and if so, was there any fallout to it???
BabyLady, BSN, RN
2,300 Posts
Here is my .
I think the argument that they are going to make is not that nurses have to back to the original chart and verify every order. However, the OP had a concern about whether or not the order, as transcribed, was correct or not.
They are going to say if she had doubts about the order, that she should have verified them with the original chart.
There is no question that the RN that signed off on the orders should be held accountable as well, as it's her job to make sure that the transcription is correct.
So after talking to my manager about the situation, I have to sign a verbal warning since in my 1st year of nursing there were two other instances of other people making errors and me not catching them "early enough". the two examples are that 1. someone restarted a heparin drip on a patient who came back postop without orders to, and I noted a few hours into my shift (i work nights so I did not see that the piggyback had fluid in it since it was dark in the room) 2. the previous nurse had recieved orders to change a PCA from morphine to dilaudid and neglected to do so while marking in the chart that it was correct. I didn't see the problem into an hour or so into my shift as well.
So as I know as a nurse it is my job to note all lines when I come into a room, but I think it is completely unfair that I have to be officially sanctioned for other's mistakes. It is like I am being set up. Totally frustrates me. I am good nurse and others mistakes are getting me set up to fail.
morte, LPN, LVN
7,015 Posts
So after talking to my manager about the situation, I have to sign a verbal warning since in my 1st year of nursing there were two other instances of other people making errors and me not catching them "early enough". the two examples are that 1. someone restarted a heparin drip on a patient who came back postop without orders to, and I noted a few hours into my shift (i work nights so I did not see that the piggyback had fluid in it since it was dark in the room) 2. the previous nurse had recieved orders to change a PCA from morphine to dilaudid and neglected to do so while marking in the chart that it was correct. I didn't see the problem into an hour or so into my shift as well. So as I know as a nurse it is my job to note all lines when I come into a room, but I think it is completely unfair that I have to be officially sanctioned for other's mistakes. It is like I am being set up. Totally frustrates me. I am good nurse and others mistakes are getting me set up to fail.
Jolie, BSN
6,375 Posts
Bark,
I understand your frustration but this portion of your post concerns me. It leaves me with the impression that you are not taking responsibility for your role in these errors. One thing we learn in nursing is that most major errors that result in patient harm or death are processes with multiple points at which the error could have been prevented or detected sooner by basic safety measures such as comparing hanging IVs to written orders regardless of the time of night. If we hold fast to the idea that we are only responsible for our own actions, we miss the opportunities to prevent these serious incidents that harm and kill patients. (Please read case studies of heparin-overdose NICU deaths for a good example.) Please remember that you are part of a team entrusted with the care of a fragile human life. Your contributions to patient safety are important. But you do not work in isolation. Have you ever had the experience of receiving a phone call from the nurse following you informing you of an error of yours that could have harmed a patient had s/he not promptly corrected it? If you haven't yet, you will. And whe it happens, that person will have your undying gratitude that his/her conscientiousness saved your patient from harm and you from a court of law and the BON.
I would like to add that you have not written anything that indicates that others have not been counseled for their roles in patient errors. Given the legal climate, I strongly suspect that they have.
Bark,I understand your frustration but this portion of your post concerns me. It leaves me with the impression that you are not taking responsibility for your role in these errors. One thing we learn in nursing is that most major errors that result in patient harm or death are processes with multiple points at which the error could have been prevented or detected sooner by basic safety measures such as comparing hanging IVs to written orders regardless of the time of night. If we hold fast to the idea that we are only responsible for our own actions, we miss the opportunities to prevent these serious incidents that harm and kill patients. (Please read case studies of heparin-overdose NICU deaths for a good example.) Please remember that you are part of a team entrusted with the care of a fragile human life. Your contributions to patient safety are important. But you do not work in isolation. Have you ever had the experience of receiving a phone call from the nurse following you informing you of an error of yours that could have harmed a patient had s/he not promptly corrected it? If you haven't yet, you will. And whe it happens, that person will have your undying gratitude that his/her conscientiousness saved your patient from harm and you from a court of law and the BON.I would like to add that you have not written anything that indicates that others have not been counseled for their roles in patient errors. Given the legal climate, I strongly suspect that they have.
i agree with morte. i see it happen all the time where i work. not so much with med errors like this, but with things like dangerously short staffed shifts and unsafe assignments, for which we have a reporting mechanism that is never used. and the reason it's never used is that people who have filed a report have been made to pay, and pay and pay. they're overlooked for career development, they're given horrible assignments, nobody helps them when they're up to their waists in alligators, they're basically blacklisted. it's unfair to punish someone for catching someone else's error "late" unless there have also been sanctions placed on those making the errors in the first place. the "old guard" will usually be protected from such sanctions and the "interloper" will be thrown in front of the bus.