Will you give out a medication without the order yet?

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Just wanted to vent.....yesterday was a very busy day. The charge RN did an admission and apparently forgot to ask the dr. for a nicotine patch for a patient who was a heavy smoker when she asked for the admission orders of the patient. I gave out all the STAT orders and then the patient asked for the nicotine patch. I said, as soon as I get the order, I'll give it. Apparently, patient told charge nurse about it. Charge nurse barges in the medication room upset asking why I was making a big deal out of "just a nicotine patch" and also said that as an experienced nurse, she knows that it was not something to make a big deal of. I replied that I was uncomfortable giving something that was not ordered for legality's sake and it wasn't even an emergency! I don't care even if they say it's "just" Tylenol, Motrin, or a Nicotine patch-----if a patient gets a reaction and there's no doctor's order, I don't want to be in trouble. Because before, one patient told me that one of her allergies was a nicotine patch-----so it's possible to have an allergy from that. To the highly experienced nurses out there, was I out of line? What are your thoughts on this? How would you have reacted?

Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
I did give the D50. I chose not to watch the pt die. I charted, charted charted. That did not stop the MD from accusing me of giving a med without an order. If you had read my post you would have seen I did the correct, unabsurd thing. I'm simply saying when you give a med without an order you are vulnerable. I can assure you I am no robot. I sweat blood that night knowing I could be putting my job on the line. And STILL I did the right thing. In this situation I had no option. Whenever I have an option, which is most of the time, I'll wait for the order.

*** There must have been a standing order D50, right? If not then your medical director and nursing administration are not doing their jobs.

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Specializes in Oncology.
Huh? Please reread my post-----my reply to the patient was: "As soon as I get the order, I'll give you the patch". So obviously I had every intention of talking to the physician. Note that the patient just came in and the orders for this patient was very new and I just gave out the STAT orders when the patient started asking for the patch. It was the patient's first time to ask me for that patch. But that's beside the point because the main issue was the CN wanted me to give something without an order yet and it was not even an emergency!

I'm sorry, I meant it as your charge nurse didn't seem to have the intention of getting in touch with the MD. You did the right thing by not giving the patch. It sounded like your charge nurse had no intention of trying to get an order, even. I meant it as your charge nurse was wrong, not you.

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Okay, thanks for clarifying.

I'm sorry, I meant it as your charge nurse didn't seem to have the intention of getting in touch with the MD. You did the right thing by not giving the patch. It sounded like your charge nurse had no intention of trying to get an order, even. I meant it as your charge nurse was wrong, not you.
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Specializes in ER/Geriatrics.
Wrong wrong wrong?

How so?

Procedurally? Probably.

Legally? Maybe, but I could have been just as liable had I not acted at all. That's the catch-22 of nursing, after all.

Ethically? Most definitely not.

If you page/call the doctor to get an order you are doing SOMETHING.

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Specializes in Critical Care.
If you page/call the doctor to get an order you are doing SOMETHING.

Not really. Phone calls don't magically heal people. If you can't get in contact with the doctor you take the appropriate emergent action and document thoroughly, including escalation up the chain.

Either that or sit on your hands and wait for the patient to code.

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Specializes in LTC Rehab Med/Surg.
*** There must have been a standing order D50, right? If not then your medical director and nursing administration are not doing their jobs.

You're right. There was a standing order. Technically, I was covered but the MD was a butt, and chose to make an issue out of it by saying HE did not give me an order. This particular doc was notorious for micro-management of his pts. It was understood, you didn't give anything to his pts without an order, standing order or not. In the short term, in this situation, I was covered. But at my hospital the rants and raves of an MD carry weight and are not harmless. Administration did not reprimand me, but also didn't spare me from the threats of the physician. I have witnessed a nurse losing a job simply because the MD demanded it. In bigger hospitals in urban areas you probably don't see this. In small rural areas, MDs can still be treated like royalty. There are a million different reasons to fire a nurse.

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You have to protect yourself.....If she wants the patient to have it, she should give it... Some of these nurses get so deep into their role they tend to forget the important stuff....you were absolutely right and I would have done the same thing..go girl

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Good Job!:yeah:

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Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
You're right. There was a standing order. Technically, I was covered but the MD was a butt, and chose to make an issue out of it by saying HE did not give me an order. This particular doc was notorious for micro-management of his pts. It was understood, you didn't give anything to his pts without an order, standing order or not. In the short term, in this situation, I was covered. But at my hospital the rants and raves of an MD carry weight and are not harmless. Administration did not reprimand me, but also didn't spare me from the threats of the physician. I have witnessed a nurse losing a job simply because the MD demanded it. In bigger hospitals in urban areas you probably don't see this. In small rural areas, MDs can still be treated like royalty. There are a million different reasons to fire a nurse.

*** OK I understand now. I am sorry that you and so many other nurses are still allowed to be treated that way. That wouldn't fly where I work but I understand your situation and you are right, a nurse can be fired any old time for any old reason.

I might be inclined to call that micro-managing physician about EVERYTHING, especially at night when he is on call. Maybe about every half hour to teach him a lesson, but then I have been fired before. Imagine, it's o300 -

Hello doctor?

YES, WHAT IS IT!?

My patient Mrs. Xyz, you know the one who had a CVA (proceed with a huge patient history until MD interrupts), well her eyes are dry and I was wondering if I could get an order for artificial tears?????

I could make a call like that about every 30 minutes.

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To the OP:

Refusing to administer a nicotine patch without an order makes all the sense in the world. Your license, your patient, your responsibility. I couldn't agree more that a charge who wants to administer it can take on that responsibility.

To the previous posters:

There were several posts which spoke to the underlying issue of when administering medications without an MD order is the right course of action. Wondering what the voices of experience think on this issue. Is it really so black and white? Is there a point when good nursing judgment outweighs the possible risk to your license or your job? In theory, it was presented to us in school, that there are scenarios which require emergent actions. The most common was administering low flow O2 to a desatting pt - then immediately calling MD. In lieu of an ideal situation, where standing orders cover emergent needs: seizure protocol - blood and lyte replacement - hemolytic reaction protocol and things like narcan/romazicon ... When do you administer? How long do you wait after you have paged and called and gone up the chain of command before you take action? I just can NOT see waiting for an Ativan order for a patient fast approaching status (or already in status). God help me if I am watching my child go into status and the RN is "waiting for orders." I also do not see myself waiting anxiously by the phone with a patient in respiratory failure and clearly in desperate need of Narcan. Am I expected to wait for serious neurological damage before administering D50 on a BG of 38? Your thoughts and opinions would be greatly appreciated.

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Specializes in Family Nurse Practitioner.

My opinion and hopefully the one of a nurse caring for me or my family is that in an emergency situation I'm doing whatever I need to do to protect my patient and if that includes starting a lifeseaving treatment prior to getting a doctor's order I am prepared to do that.

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Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
To the OP:

To the previous posters:

There were several posts which spoke to the underlying issue of when administering medications without an MD order is the right course of action. Wondering what the voices of experience think on this issue. Is it really so black and white? Is there a point when good nursing judgment outweighs the possible risk to your license or your job? In theory, it was presented to us in school, that there are scenarios which require emergent actions. The most common was administering low flow O2 to a desatting pt - then immediately calling MD. In lieu of an ideal situation, where standing orders cover emergent needs: seizure protocol - blood and lyte replacement - hemolytic reaction protocol and things like narcan/romazicon ... When do you administer? How long do you wait after you have paged and called and gone up the chain of command before you take action? I just can NOT see waiting for an Ativan order for a patient fast approaching status (or already in status). God help me if I am watching my child go into status and the RN is "waiting for orders." I also do not see myself waiting anxiously by the phone with a patient in respiratory failure and clearly in desperate need of Narcan. Am I expected to wait for serious neurological damage before administering D50 on a BG of 38? Your thoughts and opinions would be greatly appreciated.

*** The answer is "Yes & No". Yes there are times when a nurse must give emergency medications to prevent death or serious harm without having consulted a physician. As noted a nicotine patch in not in that category. No you should not give medications with out an order.

The solution, the one used in the ICU where I work and in every ICU I have ever worked in, is standing orders and protocols. Your facility must have standing orders for things like D50, Narcan, O2 and others that cover a nurse who gives them to save his patient. If you don't have such standing orders then the medical director and nursing administration have been failing in their job. I will not allow serious harm or death to come to my patient when I could have saved them by administering Narcan or something. Therefore if a hospital or unit does not have standing orders in place that allow the RN to save their patient without putting their license at risk then I will not work there.

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