Verbal order-Denied by resident

Editorial Team / Moderator · Oct 10, 2017

I love you Ruby Vee!!!

Just a tip - use the "quote" function when replying so we can tell who you are addressing. :)

Roy Fokker, BSN, RN · Oct 11, 2017

I got burned over a verbal order for 2 mg Morphine IVP on a stable patient.

Since I was dealing with a new arrival, I asked a colleague to administer the 2mg Morphine. Nurse gives the meds and goes to sign it off in the chart.

Doc, who was standing there the ENTIRE time, has not entered the order in the computer. As a consequence my colleague could not sign it off (no order!) Turned out Doc changed mind, just didn't BOTHER telling either me or my colleague.

Thankfully no harm reached the patient.

As a consequence, I got written up. Got called in the manager's office to explain myself. All kinds of detailed questioning and they mentioned the possibility of having to 'take it to the next level' (you know what that means!) It was HUMILIATING!

And this was a Doc I'd worked with for years. All Doc had to do was clarrify the situation and that would've been that. I suspect the Doc thought it was no big deal.

I have not (and WILL NOT) take verbal orders for narcs and controlled substances anymore. If I have to in an emergency, I am not leaving the Doc's side till they enter the order in the computer. And if you're a consult, FORGET IT - I'm not taking ANY verbal orders form you (narcs, meds, procedures whatever). Especially because you folks disappear at the drop of a hat (and use a different CPOE system than the ER), don't discuss crap with the ER attending and now I have to spend MY TIME chasing you down? Uh-uh. Y'all can talk it over with the ER attending and either they (OR YOU) can put the order in [consult Doc gives me verbal order for Ativan, doesn't put it in. Disappears. I ask ER Attending, who refuses to order Ativan because he doesn't think patient needs it. Good thing I double checked, yeah?]

I've worked too damned hard for my license and sacrificed much to get to where I am today.

cheers,

Traumamama02 · Oct 11, 2017

I got burned over a verbal order for 2 mg Morphine IVP on a stable patient.
Since I was dealing with a new arrival, I asked a colleague to administer the 2mg Morphine. Nurse gives the meds and goes to sign it off in the chart.
Doc, who was standing there the ENTIRE time, has not entered the order in the computer. As a consequence my colleague could not sign it off (no order!) Turned out Doc changed mind, just didn't BOTHER telling either me or my colleague.
Thankfully no harm reached the patient.
As a consequence, I got written up. Got called in the manager's office to explain myself. All kinds of detailed questioning and they mentioned the possibility of having to 'take it to the next level' (you know what that means!) It was HUMILIATING!
And this was a Doc I'd worked with for years. All Doc had to do was clarrify the situation and that would've been that. I suspect the Doc thought it was no big deal.
I have not (and WILL NOT) take verbal orders for narcs and controlled substances anymore. If I have to in an emergency, I am not leaving the Doc's side till they enter the order in the computer. And if you're a consult, FORGET IT - I'm not taking ANY verbal orders form you (narcs, meds, procedures whatever). Especially because you folks disappear at the drop of a hat (and use a different CPOE system than the ER), don't discuss crap with the ER attending and now I have to spend MY TIME chasing you down? Uh-uh. Y'all can talk it over with the ER attending and either they (OR YOU) can put the order in [consult Doc gives me verbal order for Ativan, doesn't put it in. Disappears. I ask ER Attending, who refuses to order Ativan because he doesn't think patient needs it. Good thing I double checked, yeah?]
I've worked too damned hard for my license and sacrificed much to get to where I am today.
cheers,

I agree... worked hard, with positive attitude and motivated with an open mind for 10 years... numerous kudos and peer nominations plus admin chosen awards ... not floating but for Christ's sake.. I'm not an idiot, and I am definitely not a know it all... I am humbled every day.... (to the resident and attending) so please don't flat out lie. What kind of crap í ½í²© does that to a team whose barely holding it together in the first place... we are all better than that, than this... it's not suppose to be a pissing contest... I've offered my mistakes to students and colleagues so they are mindful, I've turned myself in for giving phenergan IV when it was ordered IM and that was just last month... the point is ... I'm not a physician, I'm not even a mid level, I'm an ADN, BUT I'm a critical thinker and I put the pt first always, I look at my orders, I put in orders, I ask for help when I need it and I always offer help when I can afford to.. even when I can't I will stop and help. I'm a crappy ED nurse.. I've never given up on something I set my heart and soul out to do but I'm getting out ... neonatal air Transport is my second career goal, I've already completed my first goal which was HEMS....reason I went to the ground is bc I had a baby and jumping out of a helicopter 7 months pregnant in the dunes at glamis prooved not safe for anyone ...and going back to 48 hour shifts was not desired. Trauma center nursing was a passion, I'm sad that this happened... defending yourself is never fun especially when the focus goes south instead of on what the moral question is that's being asked...

I'm smart, I'm the cheerleader of any Dept I work in, im a happy person, I smile a lot, im focused, I'm detail oriented ... IM compassionate I'm humble, I still learn every day ... I'm a good nurse... and I've been told all of these things... as well as a lot of other not so nice things...

The culture has to change, we need to be tight with each other ... not tighten the noose ...

Please close this thread... thanks to everyone for participating. I'm exhausted and I go back to work tomorrow for the first time since the incident... be safe everyone...

2mint · Oct 17, 2017

OP, wow, hearing this, I'm so glad with our RSI policy: (Level 1 trauma center) the Attending, Resident, RT, Pharm--they draw our IVP meds; minimum two RN's.

But usually 3-4 total nurses.

RECAPS:

1. The resident handed you a primed propofol and a VO of 30mikes

2. Pt intubated

3. You proposed lower dose of propofol+Fent, Attending overrode you with Versed+Fent

4. "The attending requests [RT] to stop suctioning so we can...get an accurate [bP] reading before we start the propofol...and I have propofol [primed] and a verbal order from the resident and a discussion with the attending about changing sedation gtts and it's obviously not in the best interest to leave the pt [to] put in an order for a titration gtt that I didn't even get details for or wait for the doc to do it and then call pharmacy [to] validate it...."

5. ... so b/p is 125/88, sp02 is 86%, attending sees the b/p and walks out. The understanding is that this is an adequate [bP] to start propofol, so I start propofol at 10mikes instead of 30; I followed pharm protocol...

6. "the director is there waiting: 'did you hang propofol without an order?' 2 docs say you did"

Now, my take:

A) You have enough evidence to prove that the resident was lying.

B) You're in a tough spot: Patient Safety (~sedation ramifications) VS. Med w/o Orders

C) The heart of the matter: Was the Attending onboard with you on starting propofol?

Point #3 nullified Resident's VO.

Point #4 still no clear indications of approval; some indications of lack of details

Point #5 running propofol on assumption

D) Separate the two issues: 1-Resident lied, 2-You hung a med without an order

Lastly, thank you for posting this, I myself have been taking things for granted, this story serves to emphasize the importance of 'read back' or 'communication loop'.

Traumamama02 · Oct 17, 2017

i should have used quotes that the attending said to RT, "stop sx so we can get an accurate bp before we hang the propofol..."

its hard to get everything out in regards to facial expressions noding of heads, etc. i had orders people and pharmacy, my director and the medical director and also the resident program director are backing me up...

no disciplinary actions, an absolute learning experience. this resident does not get the concept yet and neither do many of you. its ok I'm ok you're all ok...thanks again.

as for as this thread is concerned, case is now closed with no further updates.

OP, wow, hearing this, I'm so glad with our RSI policy: (Level 1 trauma center) the Attending, Resident, RT, Pharm--they draw our IVP meds; minimum two RN's.
But usually 3-4 total nurses.
RECAPS:
1. The resident handed you a primed propofol and a VO of 30mikes
2. Pt intubated
3. You proposed lower dose of propofol+Fent, Attending overrode you with Versed+Fent

4. "The attending requests [RT] to stop suctioning so we can...get an accurate [bP] reading before we start the propofol...and I have propofol [primed] and a verbal order from the resident and a discussion with the attending about changing sedation gtts and it's obviously not in the best interest to leave the pt [to] put in an order for a titration gtt that I didn't even get details for or wait for the doc to do it and then call pharmacy [to] validate it...."

5. ... so b/p is 125/88, sp02 is 86%, attending sees the b/p and walks out. The understanding is that this is an adequate [bP] to start propofol, so I start propofol at 10mikes instead of 30; I followed pharm protocol...

6. "the director is there waiting: 'did you hang propofol without an order?' 2 docs say you did"
Now, my take:
A) You have enough evidence to prove that the resident was lying.
B) You're in a tough spot: Patient Safety (~sedation ramifications) VS. Med w/o Orders
C) The heart of the matter: Was the Attending onboard with you on starting propofol?
Point #3 nullified Resident's VO.
Point #4 still no clear indications of approval; some indications of lack of details
Point #5 running propofol on assumption
D) Separate the two issues: 1-Resident lied, 2-You hung a med without an order
Lastly, thank you for posting this, I myself have been taking things for granted, this story serves to emphasize the importance of 'read back' or 'communication loop'.

Traumamama02 · Oct 17, 2017

you need to be cloned! you're the only one that gets it...

Critical care IS different. If the provider (physician, NP, CRNA) is intubating, pushing an IV med that only someone with the proper credentials can push, or has her hands deep in the patient's chest/abdomen/name that body part, verbal orders are accepted. The understanding is that they'll put in the order as soon as possible after the situation, but sometimes they forget. That's human. Sometimes the nurse, who is busy transfusing the patient, cardioverting yet again, cleaning up the mess, catching up with charting, or changing out 27 chest tube collection cannisters in a 12 hour shift forgets to follow up. That's human, too.
What isn't human is to deny giving the order because the attending disapproves of it having been given in the first place. When that happened to me, my manager took a photo of the offender, printed it out and posted it on our dry-erase board along with a huge (3 feet tall) warning: "Do not take verbal orders from this person." By some strange coincidence, the managers of two other ICUs and both step-downs received the photo with the message. Within an hour, he was up on our unit begging to have the sign removed. My manager was happy to comply -- after he signed the verbal order, notified his attending of the situation and personally and publicly apologized to me.

Munch · Oct 18, 2017

That is one of the drawbacks of working in a huge teaching hospital(plenty of wonderful things as well). My employer has their very large school of medicine right on the same campus as the hospital(actually when I first started I was given a compass..that's how large the hospital is..over 1000 beds and many buildings). But we have so many residents and medical students and not to mention PA's, NP's, RN's, LPN's, CNA's/PCA's, techs and so on that provide care and do assessments. Sometimes the patient tends to get lost in all the providers providing care. The thing I hate most is when a resident goes to see the patient(and don't get me started lol interns..third years...chief residents...senior residents its dizzying) and a resident will tell the patient they are ordering them a certain medication. Then the attending will see the patient and not approve of the residents choice. Miscommunication happens all the time.

I don't work the ED so verbal orders really aren't relevant unless its a rapid response situation. But my co-worker got burned much like Roy did on a verbal order. Patient was in pain and the resident told her to give the patient 1mg of dilaudid. Worst part was this was in front of the patient. So my friend is waiting for the order to go through and of course the resident disappeared so she went to ask the attending if he could put the order in to which of course the attending said no way this is the third time this week this patient came in complaining of this pain, I loaded her up with morphine all week..enough is enough. Of course the resident didn't have any idea this took place. To prevent this miscommunication the attending should have briefed the resident about this patient. Now my poor friend had to clean up the mess and tell the drug seeking patient why she was not getting her well sought after dilaudid. What a mess...you can imagine my friend was verbally assaulted by this patient..I guess I can't really blame the patient who heard the doctor say yes. I guess the attending shouldn't have appeased this patient in the first place maybe she wouldn't have kept coming back...benefit of the doubt..anyway that's a whole other discussion that's been had many times before...

2mint · Oct 18, 2017

i should have used quotes that the attending said to RT, "stop sx so we can get an accurate bp before we hang the propofol..."

Yes, indeed, you should have.

Now, you're in the clear: Resident gave a VO, the Attending agreed--with RT as a witness.

Word to the wise:

When you are in the right, be calm, be composed, be a BOSS:

e.g., "The resident handed me a primed propofol and gave a verbal order for 30mikes, and the attending eventually agreed. I have plenty of witnesses." (a male nurse, btw, and a practitioner of Occam's razor).

Traumamama02 · Oct 19, 2017

you nailed it...I'm one of those who are just in awe over crappy behavior....it blows my mind; i can't fathom the audacity, thus I am having a difficult time maintaining my composure when the subject is brought up (which isn't often).

btw, the attending pulled me aside today and apologized, gave me the preceding 24 hrs of the plan of care of this patient and again ...mind=blown at the lack of ....oh I'm gonna shut up.... I refuse to become a "Bitter Betty"... but learn, learn, share, teach and learn some more... don't be mean, take accountability, practice team work, give constructive criticism, show each other compassion, empowerment is my favorite, support emotional health, hug it out often...be the nurse you'd want to work with... that is all and hope y'all had a great day and if not, hope you know that I believe in you and your passion for nursing.

Yes, indeed, you should have.
Now, you're in the clear: Resident gave a VO, the Attending agreed--with RT as a witness.
Word to the wise:
When you are in the right, be calm, be composed, be a BOSS:
e.g., "The resident handed me a primed propofol and gave a verbal order for 30mikes, and the attending eventually agreed. I have plenty of witnesses." (a male nurse, btw, and a practitioner of Occam's razor).

Anna Flaxis, BSN, RN · Oct 23, 2017

Sounds like a real cluster, and you were thrown under the bus. I'm glad the attending apologized.

**canoehead, BSN, RN** · Oct 28, 2017

I was in a situation with a resident where he wrote an order, and then denied that he had asked me to give it. There were a lot of ins and outs about the situation, but I was blamed for following what the resident told me to do. I was still getting flack two years later, there was an issue with communication and they brought up "remember when you had communication issues with that resident..." Well hell, he wrote the order, I carried it out. they took the word of a visiting resident over my statement of what was discussed when he showed me the order. Whatever.

Anyway, I asked the head of the ER to write a letter for me to the nurse manager. The docs involved had moved on, but nursing hadn't. He was incredible. Stated I had good communication skills and critical thinking, and that he would trust me with his own family. Things changed very quickly in the hospital's attitude. I can't say that approach would work, or even be appropriate in most situations, but don't roll over and agree if the facts are untrue. There were other people in the room, and if they agree, or if they even think it was unclear, you hung the drip in good faith. That's different from the doctor ordered x, but you did y, willfully ignoring his order.

EmergencyNurse2012 · Oct 30, 2017

My question is how the flip does a resident walk into an intubation with propofol in his/her hands???? Who pulled it from pyxis? Why was it already spiked? This is a MAJOR no, no in our facility (level 2 trauma center). Nurses with over 20 years experience each, recently got fired for propofol "going missing" in-between the ER and ICU. It is a serious offense and every, every drop of that stuff has to be accounted for. I've NEVER had a provider (PA, NP, MD or DO) have access to propofol without a nurse pulling it from pyxis or pharmacy preparing and giving it to a nurse to administer. Our facility had a problem with narc and propofol diversion-as a result, there are cameras at every pyxis, in triage, in pediatrics, in the hallways. Anyway, my point is, I'd have a very big problem with a resident handing me a bottle of spiked propofol-regardless of it being a RSI situation. I'd call for a facility-wide review of this whole situation and particularly how the propofol was obtained and the chain of custody. Our facility policy states we must scan the IV pump along with the patient and the medication prior to administration, the pump must be zero'd and handoffs must be done between the reporting nurse and the receiving nurse within the EMAR at handoffs/shift changes.