This RN is one of those people that you look forward to your shift when you know she is working. Great nurse, friendly and doesn't mind helping out if you need it.
A supervisor let it slip this nurse couldn't be the only RN on the floor. Of course, rumors started about narc diversion and the like. I reasoned that she wouldn't even be on the floor if this was the case, but people like to believe the worst.
I decided to look it up on my state's BON site. This nurse was working on the floor of a local hospital a year ago. One of her patients was on a vent and the family had decided to turn it off. The physician wrote an order that stated "remove life support after the patient's daughter arives at 1:00". The daughter arrived earlier than planned, said her goodbyes and after discussion with the rest of the family, told the nurse they were ready. The nurse found the RT and told her to go ahead and remove life support. The RT refused, stating that the order said 1:00 and she was waiting until then. The record didn't say how early it was, but I'm guessing it must have been a few hours since it did say the family did not want to wait until one. The nurse wrote an order that stated "ok to terminate life support now". When asked why she would write this, she said that this particular doc was one that she knew well, and every time she called to ask him for something he would say something along the lines of "whatever you want or whatever you want to do". So she felt comfortable writing the order. They went ahead and terminated life support and the patient died a few minutes later.
The record did not say who reported her to the board. It stated that initially, the BON wanted to suspend her license for two years, but settled on probation for two years. The stipulations include a minimum amount of hours to work every month, her employer has to send a letter to the BON every three months stating how she is performing, she can have only one job at a time and cannot work home health, clinic etc - has to be hospital. Another RN has to be her direct supervisor, but doesn't have to be on the same floor as she as long as the RN is in the building (which isn't what my supervisor said). The remedial education is significant and she has to pay for all of it. She went to the hearing without an attorney. Maybe the reprimand wouldn't be this harsh if she would have had one?
After finding out about this, I will never do this again and I will discourage my fellow nurses from it. The only times I've ever written orders like this are for things like air mattresses, and recently, for tele when my patient was on a drip and no monitor for three days (yeah, another story all together:madface:). I can confidently say I will never do this again. It scares the you-know-what out of me to even think about it.
I used to write "orders" if I knew the doctor would want it, harmless things. So did we all. The doctors routinely just signed their name to discharge sheets for nursing homes, too, and the nurse had to fill everything in on a blank signed paper. Just to save doctors some work. I absolutely quit cooperating in that years ago, because this is just practicing medicine without a license. Some of the older physicians had fits because they were being "bothered", and would chastise me to my face and to my manager. Too bad. That way of nursing practice has gone the way of the horse and buggy, never to return in our sue-happy society.
oh, dear. I've been practicing almost 2 years now; I work night shift, so sometimes it's practice to TOV an order for, say, tylenol prn, rather than call an MD at 2am...realistically, we're not getting sued over tylenol (of course, one would check to see if the Pt had liver problems); or, secondly, something that can only do good, not harm, like O2 protocol (RT checks Pt's O2 sat on RA, if it's less than 92%, they go on a minimum of 2L, and if O2 sat is > 92%, Pt stays on RA), or incentive spirometer...but yeah, I have to think twice, and sometimes call MD's up on night shift over things that I'm FAIRLY certain they would order anyway, but I'm not positive, just for my own peace of mind (of course, they aren't too happy about the calls, which is unfortunate, but that's life). If I worked day shift, things might be a little different.
As to written orders- some doctors may be lonely and are just asking for phone calls from the nurse.
Never thought about it that way. Now, when I call MD's up at 2am, I can get a warm fuzzy feeling inside, instead of feeling like a louse...it's like a charity, like visiting the infirmed and lonely! lol.
I should put that on needlepoint and frame it at the nurses' station. Gotta share that with the other nurses (and MD's, too!) :)
But really, who reported this nurse? I know the OP doesn't know, but I'm curious...this is end-of-life, where you're treating the family (sounds like the Pt himself/herself was unconscious), so if the family had said goodbye and was ready for life support to be dc-ed, then who made a complaint? Was it the MD, who maybe came in, saw the order, and got spooked by a nurse writing end-of-life orders? Was it some other nurse, who maybe had it in for the original nurse, or was just a stickler for the rules?
Yeah, writing an order to terminate life support is a big one; but it doesn't seem to have hurt the Pt (I mean, obviously it killed the Pt, but you know what I mean) or his family, so...
I wonder what the MD said when the BON contacted him about the issue?
I worked with a nurse who told a group of us (after another RN called in the middle of the night for a Tylenol PRN for HA order) "a lot of times I'll just write a verbal order for Tylenol and the MD always signs it." My thought was 'oh my, they might always sign it, but if you write it for someone with unknown liver issues or if they have an unexpected rxn. to the tylenol that MD is not going to cosign it.'..
oh, no, something new to worry about! Just when I was thinking that sometimes on night shift it's accepted for nurses to TOV tylenol prn...agh! pulling out hair in clumps.
hmmm...what reaction to tylenol? Have you ever known of this happening? What kind of reaction would that be? wrinkled forehead
and, not to sound bad, but wouldn't it take a few doses for the tylenol to have a bad effect on someone with "unknown liver problems"? by which time, the MD would hopefully have signed the order (I know, that sounds bad!)...but, again, that would at least point out an already existing, unknown liver problem, so that it could be treated.
but seriously, darn, now something new to worry about.
Really? Not even a 2am order for tylenol, or a clarification, say, the MD wrote "zofran 4 mg IVP q6'" and you clarify it as a prn med? Or writing "NPO p MN" for a Pt who's having a procedure/surgery in the morning...nothing like that?
The only time I will EVER write a MD order without calling is when I need to get a med from the e-box that the resident already has an order for but we don't have any left and are waiting for pharmacy to deliver(which can take at least a day).
Flame me people.. lol. Next time I need to do that you can come in and call the doctor for me.
Several people have commented that they would not take a verbal order to discontinue life support, especially in this case where the family wanted it earlier than the time written by the physician.
I, however, would...but I would take an additional step to CYA unless facility protocol required him to be there.
I would make sure that he talked to another nurse at the same time and have both RN's co-sign the verbal order.
He would really have a hard time defending that if he tried to refuse to sign it later.
One place I worked people (not me) would give tylenol without an order all the time, but of course they never charted it as being given (because there was no order). Makes it awkward for the nurse that won't give it without an order when the patient asks for it.
However, I would not give it without a specific order and I would not write my own order for it, even if it is only tylenol.
Even if the patient is already on TC#3, sorry doc, need a separate order for plain tylenol.
Particularly with computer charting, how do you document giving a med that
what reaction to tylenol? Have you ever known of this happening? What kind of reaction would that be?
I know that people can be allergic to just about anything...google "allergic to tylenol" and you get some hits. Yes, it is rare. However, if I write an order under a doctor's name without actually talking to him/her, I am guessing most will not cosign my verbal order for tylenol after the pt had a rxn to it.
Wow... I don't write orders without talking to the dr first, no matter how late. I mean, its not really that bad to call anyway. Just make sure you're prepared "Sorry for waking you up, pt has a temp of 101.9 but nothing PRN, can I please have some tylenol PO for that?" or SOMETHING. Keep it short and sweet and usually they don't get mad =)
allthesmallthings
157 Posts
oh, dear. I've been practicing almost 2 years now; I work night shift, so sometimes it's practice to TOV an order for, say, tylenol prn, rather than call an MD at 2am...realistically, we're not getting sued over tylenol (of course, one would check to see if the Pt had liver problems); or, secondly, something that can only do good, not harm, like O2 protocol (RT checks Pt's O2 sat on RA, if it's less than 92%, they go on a minimum of 2L, and if O2 sat is > 92%, Pt stays on RA), or incentive spirometer...but yeah, I have to think twice, and sometimes call MD's up on night shift over things that I'm FAIRLY certain they would order anyway, but I'm not positive, just for my own peace of mind (of course, they aren't too happy about the calls, which is unfortunate, but that's life). If I worked day shift, things might be a little different.