What should I do? I think I goofed!!

[WinterGirlyRN]

Hi,

I'm a new RN with only 2 months of working solo under my belt. I think I goofed big time.

I had a pt last week who had a PRN order for Tylenol in suppository form. It had been order Rectally when he had previously had an NG tube and was NPO. So he developed a bit of a temp and he refused the rectal form and asked for PO. Heres my goof....I entered the order using the same MD who had ordered the rectal form without calling said doc.

How bad did I goof??

Why did I not call? Because the docs yell at me everytime I call them unless its for something urgent. I was having a bad night and coulldnt take another ticked off doc.

Help? Did I really screw up?

[ChristineN, BSN, RN]

Here's a thought from another newbie. I know sometimes docs order pts on my floor liquid Tylenol, and other RN's will override the order to give the pt a pill. Could you have done the same thing, over rode suppository for pill?

[Virgo_RN, BSN, RN]

Do you have a pharmacist available? Sometimes, depending upon the medication and how the order was initially written, pharmacists may change the route, sparing you the phone call to the doc.

Another thought, sometimes I will take dilemmas like this one to the charge nurse. Typically, the charge nurse has been around long enough to know which doctors would be okay with signing the order later, and which ones are likely to get their hackles up if you change the route without calling first.

If both of those options do not work, then you have to call (unless, as a previous poster mentioned, you let the patient know that their choice is to take the suppository or wait til morning).

I know docs can get annoyed when you call for minor things like that, especially at odd hours. Nevertheless, they should not raise their voice to you or be disrespectful.

[thinkin' about it]

posted by ruby vee:

"i might have done the same thing if i knew for sure the patient could handle the po med, and if i knew the doctor well. but then i've had 30 years (plus) of exprience, and you've had a couple of months. you've probably seen the experienced nurses around you do the same thing, but you're not in a position to do that. so you goofed. not big time, but you shouldn't have done that, and it could come back and bite you in the butt."

sorry, ruby, i respect your knowledge and many years of experience.....but.....in the eyes of the law and honesty, you are just as wrong in doing this as a new grad. in addition, every time you do this, you are making things more difficult for newer nurses and nursing in general, as doctors come to expect this from nurses, because they are being coddled by nurses who are easing their burden by practicing outside their scope of practice. so, you are also not in a position to do this. legally, there's no gray area here.

[Ruby Vee, BSN]

ruby, should i call the doc and let him know what i did? i feel the need to be truthful about this. should i tell me nurse manager too?

you should. and when you talk to them, confess that you hadn't thought it through when you did what you did, but now that you have, you understand the implications and you're soooo sorry and it will never happen again! usually, if you impress upon them that you're beating yourself up over it, they won't be as inclined to try to tear out a strip of your hide.

[Ruby Vee, BSN]

posted by ruby vee:

"i might have done the same thing if i knew for sure the patient could handle the po med, and if i knew the doctor well. but then i've had 30 years (plus) of exprience, and you've had a couple of months. you've probably seen the experienced nurses around you do the same thing, but you're not in a position to do that. so you goofed. not big time, but you shouldn't have done that, and it could come back and bite you in the butt."

sorry, ruby, i respect your knowledge and many years of experience.....but.....in the eyes of the law and honesty, you are just as wrong in doing this as a new grad. in addition, every time you do this, you are making things more difficult for newer nurses and nursing in general, as doctors come to expect this from nurses, because they are being coddled by nurses who are easing their burden by practicing outside their scope of practice. so, you are also not in a position to do this. legally, there's no gray area here.

i work in an icu, and we're within our scope to do this -- but i'd tell the prescriber just as soon as i saw them. and you're right -- i could be in trouble, too, if the prescriber wanted to make trouble.

[thinkin' about it]

posted by ruby vee:

"i work in an icu, and we're within our scope to do this -- but i'd tell the prescriber just as soon as i saw them. and you're right -- i could be in trouble, too, if the prescriber wanted to make trouble."

i just want to be sure i understand. do your policies actually support writing a doctor's order when you haven't spoken to a doctor in person or on the phone? because that seems to be what the issue is here. i'm not talking about writing something as a nursing protocol, because there are written protocols to cover some things the doctors have agreed they don't want to be called on, like a stat ekg for chest pain. that's not the question, though. i'm talking about writing something as a verbal or telephone order, as is the issue with the op? how are you within your scope to do this, even in icu? i know it happens, but it was my understanding it is outside the scope of practice, plus dishonest because it's stating you spoke to a doctor you never spoke to.

i really mean no disrespect. i'm just curious.

[CarVsTree]

You know, everyone is telling OP to tell the doc. The same doc who yells at her regularly. Suppose he tries to make an example of her. These are the consequences:

1.) Verbal/Written Warning.

2.) Fired.

3.) Reported to the Board of Nursing for practicing medicine without license, falifying, etc.

4.) Doc that yells at her understands and appreciates her not calling him...

OP, you have to decide how you think this will pan out. How long ago was it? I know it is important to be honest, but perhaps you should talk to someone you trust with experience and knows the doc, the management at your facility, etc.

Also, I would be careful about admitting to wrongdoing on the internet. This is a public record. I never discuss details about what I do or do not do at work. I discuss generalities, occasionally, ask questions, but never details. Just a thought.

[Spidey's mom, ADN, BSN, RN]

The order will be flagged for the doc to sign and he will see it. You can't keep it a secret.

steph

[WinterGirlyRN]

I'm going to fess up to the Dr and hope he doesnt rip my head off.

I am so sick to my stomach over this. Its all I've been thinking about for the past day.

Thanks for all your suggestions and comments. I know for sure I will learn from this one.

[Batman24]

Best to come clean. Keep it short and simple. Don't go on and on. Hopefully if worded right it won't become a huge issue and they'll just sign. Do it now and get it done versus continuing to stress over it.

And the biggest lesson you should learn from this is not to fear calling a doc to do their job. You ut yourself at risk here due to it. If they yell you need to learn to deal with that or it won't stop.

Good luck!! :)

[Ruby Vee, BSN]

posted by ruby vee:

"i work in an icu, and we're within our scope to do this -- but i'd tell the prescriber just as soon as i saw them. and you're right -- i could be in trouble, too, if the prescriber wanted to make trouble."

i just want to be sure i understand. do your policies actually support writing a doctor's order when you haven't spoken to a doctor in person or on the phone? because that seems to be what the issue is here. i'm not talking about writing something as a nursing protocol, because there are written protocols to cover some things the doctors have agreed they don't want to be called on, like a stat ekg for chest pain. that's not the question, though. i'm talking about writing something as a verbal or telephone order, as is the issue with the op? how are you within your scope to do this, even in icu? i know it happens, but it was my understanding it is outside the scope of practice, plus dishonest because it's stating you spoke to a doctor you never spoke to.

i really mean no disrespect. i'm just curious.

our doctors have agreed they don't want to be bothered with something like switching the route of a medication that's already ordered (in this case, pr tylenol) as long as the patient can tolerate pos. i've never heard of one objecting to that -- although they probably would object (and rightly so) if you changed the route on just about anything else. but the more i think about it, the more right you are. it's not strictly kosher and could come back to haunt us. suppose you gave po aspirin rather than pr to someone with an ugi bleeding history and it caused a problem?

[Virgo_RN, BSN, RN]

Different units have different protocols. On the med/surg unit where I precepted, nurses routinely stopped IV fluids when the patient started eating, even if the little box to "saline lock IV when taking PO" hadn't been checked by the MD, because it was protocol. Nobody was going to call the surgeon and tell them they forgot to check the box on the postop orders and ask for permission to saline lock. Is this by the book practice? No. Is it real world practice? Yes.

On my unit, cardiac, we don't stop IVF without an MD order (unless the patient is too wet, then we stop the gtt and call the MD). On a unit where patients are routinely NPO, and have orders for meds via alternate routes, it's possible that switching to the PO route once the patient can take PO is acceptable practice. That's why I suggest asking the pharmacist first. Pharmacists do have discretion on certain things and can write orders within certain limitations.

Just the other night, I had to call the cardiologist on call because the cardiologist who did the intervention on one of my patients forgot to fill in the little blank saying how long to continue the Integrilin gtt. I know protocol is 12, sometimes 18 hours, but that was, in my opinion, going beyond basic nursing judgment. Of course, the cardiologist I got was The Grumpy One (aka Dr. Ray of Sunshine), and of course she complained about being called, but I got the order and covered my butt.

Some things, not such a big deal. Others, big deal.