Reading the note wrong and thought MD note was an order

[xmsanta]

So the story goes like this. I am a new nurse for about 8 mths now. The patient was having febrile neutropenia with 2-3 episodes of a spike of temp at night for the past 2 weeks, no sign of infection, have cancer, and was getting chemo. The nurse last shift told me not to give the meropenem if the blood culture was negative in the shift change report. I re-read the MD note and I thought the MD note also said that and I took the note as an order (Apparently I read the old note, the MD added a note saying to continue the abx after, which I did not read). The blood culture was negative, and I did not give 2 doses of the meropenem as a result. In the day shift, my buddy nurse texted me and told me the family was upset that the pt missed the 2 doses of abx. The family was very upset and the pt was crying over missing the 2 doses of abx and that I did not give the 2 doses of abx without an order. The day nurse received 6 phone calls from the family. The MD and the day shift nurse had to apologize. I think the pt received the final dose of abx today from the day shift nurse in the end. 

I feel like I got no one to talk to that could empathize so I am writing here. I feel sorry for the pt, the family, the MD, and the day shift nurse. I feel like I let them down and it was dumb of me. I know that I can't blame anyone because I am the one making the final decision. Though I feel sorry, I am also scared about what will happen to me and if the pt will be okay. What do you guys think? I just want the honest truth and not just comforting words. ?

[egg122 NP, MSN, APRN]

We all make mistakes in healthcare. The important thing is to learn from them. This likely did not result in any harm. If it comes it, just acknowledge you made a mistake and how you will take a different course of action in the future if a similar situation arises (such as calling the MD to clarify if you get a verbal report to hold the abx but do not see an order in the order section of the chart).

[JKL33]

5 hours ago, xmsanta said:

Though I feel sorry, I am also scared about what will happen to me and if the pt will be okay. What do you guys think? I just want the honest truth and not just comforting words. ?

Why don't you call your manager (or ask to meet briefly with him/her) and just get it out in the open. Just say you are aware of something that you could've done differently and need a second to talk about it.

You don't need the stress of sitting and worrying whether you're in any kind of trouble. Plus it's usually not a bad thing to be open about things like this; people tend to appreciate that a lot more than some other choices.

Your patient will probably be no worse off for this, although that's kind of a wrong thing to focus on. Obviously every nurse can't decide to operate this way or patients are going to be worse off.

You learned something. You need orders for the kind of actions you took. So next time someone reports something like this to you, you'll remember that your first task is to verify orders.

It'll be okay. ???

[_firefly, BSN, RN, EMT-B]

Was this a paper or electronic note? Either way, notes should be banned. They just create this kind of confusion. Doctors should stick to orders and putting them in themselves. 

[JKL33]

5 hours ago, _firefly said:

Was this a paper or electronic note? Either way, notes should be banned. They just create this kind of confusion. Doctors should stick to orders and putting them in themselves. 

What? They serve a significant purpose.

I have no idea why banning notes would be an answer to a nurse acting without an order.

[amoLucia]

JKL33 - agreeing. Progress notes often project future plan of care.

They're invaluable.

[Corey Narry, MSN, RN, NP]

18 hours ago, amoLucia said:

JKL33 - agreeing. Progress notes often project future plan of care.

They're invaluable.

Plus that's how providers (or the hospital) get paid for their services. LOL.

@xmsanta, we will all make mistakes in our career.  I've made them and anyone who says they haven't ever is lying.  Like others said, I would approach this is an opportunity for learning.  I bet you will remember to check the order before holding a medication from now on and that is a good outcome of this.  On the positive side, I always appreciate nurses who read providers progress notes because as mentioned, it helps inform them of the plan.  But notes are time specific as you already found out.  They are written at the time the patient was assessed by the provider and the plan only applies to that time frame. 

If you haven't done so, it would help you feel better, to talk to the dayshift nurse and the MD and I bet they will appreciate that.  The MD, can actually give you a better picture of his concern for continuing the antibiotic and whether doing so was such a big deal or not.  Medicine relies a lot on risk-benefit ratios and probabilities - in many cases, decisions are based on ratios that fall somewhere in the middle. The fact that your post said the last dose of antibiotic was given tells me this is a low risk patient.  Families, on the other hand, understandably want everything done for their loved one.  Their reaction is typical in such a situation.

[Daisy4RN]

I would not worry about this too much. Sounds like good advice so far and that you have already learned a valuable lesson; notes are not orders (ever) and if not sure than clarify with the MD (esp with cancer pts who are very susceptible to infections, depending on where they are it could be significant). There is much going on with Cancer pts so you can (just about) always expect that type of reaction from family. 

You sound like a caring compassionate nurse, and as others have stated, we all make mistakes! 

[JKL33]

17 hours ago, juan de la cruz said:

On the positive side, I always appreciate nurses who read providers progress notes because as mentioned, it helps inform them of the plan. 

Yes. In my very first nursing position I was caring for fairly sick patients but usually had a little period of downtime at a particular point in the night and I poured over my patients' very thick charts. I feel that what I learned is as much a part of my nursing foundation as just about anything else.

I'm glad you pointed this out as I would never want to give the impression that the orders are the sole important thing to which nurses should pay attention. ??

[JBMmom, MSN, NP]

I'm sure that things will be okay. Your story highlights one of my pet peeves in our current system. Holding a medication is an order. You should not be getting a verbal report note from another nurse saying it should be held. The doctor needs to enter an order (our system has nursing communication orders) specifying that if a lab result is this, the medication should be held. MD notes aren't orders, they're notes. They're very useful for many things, but when doctors don't use the correct tools, they can be a problem. I have seen so many consult notes where doctors write "consider discontinuing xxx medication", and that's it. No order. Do they expect the hospitalist to read their note and enter an order? Do they expect someone else to make the final decision and enter an order? I don't know. I've had more than one physician come in and question why something was still running as an infusion or administered. I have finally gotten to the point where I'm very comfortable telling them I had no order. If they wanted one based on their note it needed to be entered. 

Sorry it turned out to be a rough situation for you. As others have mentioned, probably not going to harm the patient. Take care.

[JKL33]

On 12/7/2020 at 11:30 AM, JBMmom said:

I have seen so many consult notes where doctors write "consider discontinuing xxx medication", and that's it. No order. Do they expect the hospitalist to read their note and enter an order? Do they expect someone else to make the final decision and enter an order?

Yes they do, that's why they wrote it the way the did instead of writing an order to discontinue the medication. They are the consultant and they want the primary admitting service to mull it over in conjunction with the rest of the patient's picture knowing that this consultant's assessment based on their specialty expertise is that the med in question might have something to do with xyz problem.

This is part collegiality and in large part a matter of safety. Think about it. You can't have one service ordering something and another service coming around and discontinuing the order (especially without the benefit of knowing why it was ordered in the first place). I know things like this happen but on the whole it certainly would not be an organized and safe manner of adjusting the patient's treatment plan.

On 12/7/2020 at 11:30 AM, JBMmom said:

when doctors don't use the correct tools, they can be a problem.

Well, we do all know that sometimes they don't use the correct tools. But writing a specialty assessment or opinion or writing  thoughts for others' consideration in the notes section where all the services communicate with each other, is not an incorrect use of physicians' notes.

On 12/7/2020 at 11:30 AM, JBMmom said:

I have finally gotten to the point where I'm very comfortable telling them I had no order. If they wanted one based on their note it needed to be entered. 

That's fine. But maybe it isn't a case of them having wanted you to discontinue something based on their note (which they know is not how to discontinue something they are responsible for discontinuing) but rather just a case of them wondering if the other service read their note and why the other service didn't take their advice. Which represents them doing what they do often do, which is asking their question to the wrong person--that wrong person very frequently being the nurse who happens to be standing there.

[JBMmom, MSN, NP]

10 hours ago, JKL33 said:

Yes they do, that's why they wrote it the way the did instead of writing an order to discontinue the medication. They are the consultant and they want the primary admitting service to mull it over in conjunction with the rest of the patient's picture knowing that this consultant's assessment based on their specialty expertise is that the med in question might have something to do with xyz problem.

This is part collegiality and in large part a matter of safety. Think about it. You can't have one service ordering something and another service coming around and discontinuing the order (especially without the benefit of knowing why it was ordered in the first place). I know things like this happen but on the whole it certainly would not be an organized and safe manner of adjusting the patient's treatment plan.

Well, we do all know that sometimes they don't use the correct tools. But writing a specialty assessment or opinion or writing  thoughts for others' consideration in the notes section where all the services communicate with each other, is not an incorrect use of physicians' notes.

That's fine. But maybe it isn't a case of them having wanted you to discontinue something based on their note (which they know is not how to discontinue something they are responsible for discontinuing) but rather just a case of them wondering if the other service read their note and why the other service didn't take their advice. Which represents them doing what they do often do, which is asking their question to the wrong person--that wrong person very frequently being the nurse who happens to be standing there.

So the problem comes in when I contact the hospitalist or attending and ask about that particular order and their response is that they are not responsible for the orders related to consulting physicians. For example, recently we had a patient on an amiodarone drip which has specific parameters and hangs for a specified amount of time. The consulting cardiologist wrote in the note, consider continuing amiodarone infusion until patient can take PO medication. However, no one ordered the infusion to continue, so it fell off the MAR. I read the note and contacted the overnight hospitalist and they said they would not change orders related to a cardiology specific medication. I called the on-call cardiologist, got no response, and this was already late in the shift and I didn't get to follow up again because of an actual emergency- this patient was stable. When the cardiologist rounded in the morning, they were annoyed that the amiodarone had been discontinued and the statement they made was "I said it should be continued". So in their mind "consider continuing" translated to an order that someone should write, but no one did. In MANY cases, there seems to be no one that will actually take the responsibility to write an actual order. Patients with certain conditions get kicked from consulting physician to consulting physician and no one makes the necessary changes in care.  

I appreciate your perspective related to how things should work and why collaboration is necessary, and I agree. However, sometimes things don't go as they should and it often comes back on us nurses when things didn't come together.