Verbal er orders...help me understand this

sapphire18 · Sep 26, 2012

Verbal orders always make me nervous that this would happen...I really have no advice here but you may want to consult a lawyer.

sserrn, BSN · Sep 26, 2012

First of all, what a crappy thing to do on the pa's part. Second, I don't give any narcotics w/o a written order, and policy states (in both facilities where I work) the only time we can receive verbal orders in the ER is in life-threatening, critical situations. As far as what to do now, I would fill out an incident report if you haven't already; have a face-to-face meeting with your supervisor; and consider consulting a lawyer if you feel like it is that serious of a situation. Does your ER have a policy on verbal orders? If they are allowed, I don't see the problem here; why would you be medicating pts w/o an order? It seems pretty suspicious on the pa's part. Was there a bad outcome with this pt.?

iluvivt, BSN, RN · Sep 26, 2012

This makes very suspicious that something happened to the patient or that there was some kind of complaint. It is suspicious for the PA b/c is sounds like they are making you a scapegoat. Did you do any type of documentation stating that the MS was ineffective in decreasing the pt's pain score to a tolerable level and that you communicated this to the PA and MD and obtained an order. I know that sounds like a lot of work in a busy ED but you can see how that would benefit you now.

You need to review your charting to see if it supports you. Perhaps this PA has had nurses do this before and is hypersensitive to the issue and simply cannot remember giving the order. I can see this happening easily and I always tell MD on verbal orders and TO's that I will be documenting our conversation. The PA is questioning you veracity..that is what is happening here...make no mistake about it....the PA is calling you a liar and saying you are practicing outside of your scope of practice and you falsified the order. maybe the PA's veracity needs to be questioned right back!

You need to state concisely and with no hesitation how it is that you obtained the order. You followed the nursing process..performed you assessment and pain assessment using a pain scale and took in account the pain medication already administered and you then contacted the PA and MD for orders. That way your actions support your assessment and a prudent nurse would report that and seek a higher dose or medication change and it is logical to do from MS to Dilaudid, so it all makes sense. DO NOT BACK DOWN. Why would a nurse in good standing just suddenly start doing something like this without ever doing it before. I would never take a verbal order from the PA again.

Give me a break...the PA is freaking out about 1 mg of Dilaudid. My feeling is that PA gave that order and has some kind of ax to grind.

morte, LPN, LVN · Sep 26, 2012

Yup, that PA is now persona non grata. deal with he/she as little as possible, and insist on all orders being put in the computer before execution.

Esme12, ASN, BSN, RN · Sep 26, 2012

I work in california, have worked in the same facility for 3 years, have never been written up for a med error or been disciplined for my work ethic in the er. I received a phone call today from my manger stating that the verbal order from the pa for 1 mg of dilaudid was not signed by the pa and that the pa stated that the verbal order was never given to me and the pa filed a formal complaint against me stating that i was acting as a md and was called to have a formal hearing with my union rep about my job. I not only got the verbal order from the pa but also confirmed with the md....who i am hoping recalls and will sign the order off........the comment made to me was that the pt already received 8 of morphine.....which did not relieve the pt's pain.......and s/p xrays was vocal and crying s/p a motorcycle accident with a r/o fx to the left ankle. Pt had a hematoma from the ankle to the shin and a previous ankle fx. It was approx. 45 mins to an hour.....before the dose of dilaudid. It is standard practice in the er that we take verbal orders.....as we have 1 or 2 md's on and maybe a pa......at any given time and on nights we have one md only. I would never act out of malice or give a pt any medication if i did not think i had an order. My job is on the line here.....i need thoughts and prayers please......

I am sooooo sorry this happened to you.

You need to check you facilities policy and see what EXACTLY it says, and notify your malpractice insurance immediately. Just because it is "standard practice" doesn't mean it falls within the policy. There have also been recent changes from The Joint Commission and CMS have issued new guidelines that have stricter regs for authentication of orders within 48 hours.MedLaw.com :: CMS Verbal Order Rule Effective January 26

Authentication of verbal orders. This regulation requires that all orders, including verbal orders, must be dated, timed, and authenticated by the prescribing practitioner with a temporary exception. For a five-year period beginning with the date of publication of the final rule, the regulation requires that all orders, including verbal orders, must be dated, timed, and authenticated promptly by the prescribing practitioner or another practitioner responsible for the care of the patient, even if the order did not originate with him or her.

It is clear this PA is throwing you under the bus. There may also be State law specifying the time frame for authentication of verbal orders need to be authenticated within a certain time frame etc.

I have worked in the ED for a long time in a couple of states and several ED's and they all have had a NO VERBAL ORDER policy......even when it is not enforced.......except in "emergent" situations due to occurrences just like this one....and worse. I have actually seen great nurses fired because of verbal orders whether or not there is a no verbal order policy. A common verbal order policy states that verbal orders may be given only if the patients life depends upon the order and during resuscitative situations and must be authenticated within 24 hours.

That you belong to a union may help you....I knew a really good nurse this happened to....the union stood behind her for even though there was a no verbal order policy, unless it was an emergency, it was standard operating procedure and standard of care.....she still got fired by the facility but the Union sued for wrongful termination and won. "Everybody does it" and "I had no idea there was a policy" won't save you and I have seen many doc's that I trusted and adored turn into sniveling lap dogs for when it comes between them being in trouble or you.....guess who is talking the fall.

I know that there are behaviors that occur within the ED that are "usual and customary" and not necessarily within policy and procedure like verbal orders......everybody does this won't protect you . I would avoid this with his uhmmmm:rolleyes: "provider" at all costs. I would hand him the chart to him and be sure to tell him that you are happy to follow any of his orders.........AFTER he has written them properly on the chart so that there can be NO miscommunication like that one time.......smile sweetly and hand him the chart for him to write them:smokin:....... because if the patient isn't coding...he can write them.....if he is in a code......most things can wait a few min so he can write them.

I am so sorry this happened I wish you the best.:hug:

NurseOnAMotorcycle, ASN, RN · Sep 26, 2012

Yeah I'm sorry this is happening. There is a PA here with exactly that reputation. Really nice to your face, but throws nurses under the bus. Because of him, there's that same unwritten law: Not without written orders unless in a code! It makes it harder for the more honest ones, but they're understanding about it.

Bad PA: Give Smith 1 of dilaudid.

Wary Nurse: Ok, I'll draw it up while you put it in the computer.

Bad PA: Humph. Ok.

CrunchRN, ADN, RN · Sep 26, 2012

Hope it all works out. It does sound like you are being thrown under the bus.

Altra, BSN, RN · Sep 26, 2012

Verify the policies of your department and your hospital -- are PAs permitted to order Dilaudid?

morte, LPN, LVN · Sep 26, 2012

Per OP, order was confirmed with MD. Hoping for written confirmation from same.

Verify the policies of your department and your hospital -- are PAs permitted to order Dilaudid?

Patti_RN · Sep 27, 2012

This is the danger of taking verbal orders from anyone, especially from those you don't have a long-standing, trusting relationship with... and even then, if it comes down to your job or theirs, they may suffer from cloudy memory in order to save themselves.

The current state of over-supply of nurses makes RNs fairly disposable--that's the unfortunate consequence of far too many grads for too few positions. You're replaceable; someone is waiting in the wings to take your job as soon as you collect your last paycheck.

Things like this (the PA back peddling and denying that she gave a verbal) don't happen unless there was a subsequent problem. And, that problem could have been anything from the patient complaining of itching to the patient dying. So, no matter how minor or major the issue, the PA is going to cover her butt and claim you didn't have an order. And, the problem is you didn't have an order (well, OF COURSE you had an order, but not one you can prove). In a 'worst case' this goes to court and you're sitting on the witness stand trying to explain to a jury of non-medical folks that the PA told you to give a narcotic... the hospital's lawyer or the deceased patient's lawyer is going to ask you where that piece of paper was. Then he/she is going to pull out all the hospital’s rules and regulations about verbal orders, and all the laws about dispensing narcotics, and all the lessons you got in nursing school about ‘the right patient, the right drug…” No matter how much you try to explain, you’ll look worse and worse. And in the event of this ‘worst case’ scenario, the hospital will distance itself from you to save itself. So, early on, far before this goes to court (if it ever would) the hospital will protect itself and claim this is not standard procedure and you had no right to act independently. They may very well be doing this ‘distancing dance’ now.

If it were so easy to refuse all verbal orders, we’d do so. But, that brings a different risk: the risk of delay in providing urgent or emergent care to the patient. Refusing to carry out verbal orders denies the patient of quality care. Refusing verbal orders also risks your job as you’d be seen as difficult and uncooperative.

We always want justice and it’s in our culture to believe the good guy always wins. Sadly, this isn’t the case. There is no perfect solution—and maybe not even an acceptable solution. You were caught in a no-win situation. Appeal to your union, alert your malpractice carrier, and talk to your supervisor. Best of luck.

ProgressiveActivist, BSN, RN · Sep 27, 2012

From now on when this PA and MD give you a med or treatment order, in neutral voice say:

"here's the chart can you write for that?"

Let them know that the trust is broken when it comes to verbal orders-and they are the ones who broke it.