What should I do

[Mashira]

This is what I have written:

To Whom It May Concern:

Writer contacted Dr. X on 8/18/11 at 0235 from XYZ Unit. A patient of Dr. X was agitated, yelling, verbally aggressive, threatening physical aggression, oppositional and progressively escalating throughout the night. The patient was threatening to kill an opposite sex peer on the unit. The patient was posturing, walking towards, cursing at, and threatening staff and above mentioned peer. The patient severely agitated the opposite sex peer, who also began posturing towards patient and pacing.

Dr. X was informed of the situation, as well as of the patients refusal of previously prescribed PRN agitation medication. The patient requested to staff a dose of their regularly scheduled anxiety /agitation medication. The patient request was relayed to Dr. X by writer.

Dr. X began to loudly address writer, asking why he was being bothered with the situation at 0235 in the morning regarding a patient request for scheduled medication. Writer readdressed the patient situation, clarified and emphasized the urgency and agitation of the patient, and detailed the patients threats. Dr. X continued to question the necessity of being called at 0235, stated, “Haldol Ten”, and disconnected the phone line. No route or frequency was specified. The patient refused any medication, and therefore a phone call was not made to clarify the prescription. In order to use the least restrictive intervention possible, the patient did not require a Special Treatment Procedure. Although labile, the patient was willing to speak with staff. Writer processed with patient until patient was able to control behavior.

As previously stated, the ordered medication was refused, and the patient continued to intermittently escalate. Had the patient not been willing to process with staff after Dr. X was called, the unit staff, milieu, and other patients were at potential risk for harm. The act of disconnecting before clarification of an order, and unwillingness to listen to a situation that posed a threat to both staff and other patients put the safety of the unit at risk.

Opinions please. Is this professional/factual enough? Would you file the grievance or let it go as a "butthole doctors, what do you expect" kind of thing?

[MrChicagoRN, RN]

That was scary, glad to see it resolved peacefully.

So, who is "to whom it may concern?" What do you plan to do with the letter?

Have you followed the chain of command?

Have you discussed this with your nurse manager or the unit medical director yet?

I also found it wordy & kind of stilted, and there is no mention of any attempts to deescalate the patient prior to the medication request. Why were the patients allowed to remain in proximity to each other?

"On 8/18/11 during the night shift, Pt A.B. became agitated & verbally aggressive, theatening physical violence. Pt continued to escalate, cursing at staff, and threatened "to kill" a female patient. In response, this other patient became agitated and began pacing and posturing. RN contacted Dr. X on 8/18/11 at 0235. Dr. X was informed of the situation, as well as of the patients refusal of previously prescribed PRN agitation medication. The patient requested to receive a dose of their regularly scheduled anxiety /agitation medication. "

Was the patient requesting to receive their 9am medication a few hours early? Was there any medical contraindication to giving the medication then, and notifying the MD later in the morning?

Most medications are ordered once, twice, three times a day or whatever. While hospital protocol and convenience may say morning meds at 0900, the patient's welfare is paramont and most policies allow a med to be rescheduled according to nursing judgement.

[Davey Do]

This is where I am with this situation:

I'm very okay with giving a scheduled dose of a med, per physician's orders, at a time different than that on the MAR without consulting the Doc. I always document the time on the MAR, in the Nurses Notes, and pass the info on in report.

This could be a reason the Doc went off- this is something which is is understood- as MrChicagoRN said, this type of stuation calls for "nursing judgement".

Creatively dealing with situations, such as having the hadol ten order thrown at you is another area of nursing judgement. Based on the info I was able to discern, I would have taken the order as a "one time" or "now" order and read it back (if only to myself) as "Haldol 10 mg IM/PO now for agitation" and proceeded to use it therapeutically.

I would not suggest sending this statement to anywhere but your own archives. You could keep it if a need arises, or reread it at a later date to see if your perspective has changed.

It's all in the name of learning the game, Mashira. The best to you.

Dave

[Mashira]

Update: Took it to the nurse supervisor. Nurse manager said the behavior was unacceptable. We are not allowed to give any med at our facility, even a scheduled med, more than one hour prior to it's scheduled time without the docs order. Supervisor told me to file a grievance with HR, at which time it will go to the CNO, who will take it to the CEO of our small private facility. CEO will give it to medical director.

The chain of command agreed that considering the patient population of my unit (extreme acuity, just flat dangerous patients) the doc was far, far out of line.

Dave, I agree with you as well as MrChicago, however the messed up policies at my hospital prevent me from making that 'nursing judgment' call, and would instead have called it 'practicing medicine' and had me kicked out. Screwy, I know.

[MrChicagoRN, RN]

But you did take it to your manager, and followed the chain of command, which is the important thing.