Worst doctors orders ever received

[jenfromjersey]

I have a two nursing degrees, going for a third and have a whole lotta common sense. When I see stupid or hear stupid orders I may or may not carry them out..here are my all time favorites:

1) Male patient with active lower GI bleed...HGB of 5...Hypotensive and tachycardic..has 2 large bore IVs running with NS wide open as fast as it will go...blood bank working as fast as possible to get me my units of PRBCs ASAP...BP barely 90 systolic.

Order from resident: "We need orthostatic vitals on this patient"

[Ruby Vee, BSN]

how about the pregnancy test insisted by an attending ( yes, that's right, attending!) on a 68 yr old nun? p.s. that md no longer works for my hospital.

i'll grant you that at 68, she's unlikely to be pregnant. but my ex-husband cheated on me with a nun, so i'm not thinking nuns are exempted from pregnancy tests!

[cherrybreeze, ADN, RN]

"Do not let patient leave AMA without permission from psych."

Did we forget what "AMA" means??

[PetiteOpRN]

Part of my job is to return the MD's pages while he is scrubbed in. Today I returned a page and the RN on the line said, "I need to clarify an order...I am not going to do what is ordered...we need to clarify this..."

me: "...go on..."

"Dr. Resident ordered 40mEq KCl IV now."

I report to Dr. Resident who responds "K is 3.1." Well, that clears everything up!

"Is that as a push or diluted?"

"Go ahead and dilute it"

me:"...go on..."

Finally he gives the order to dilute w/ 250ccNaCl and run over 4h.

Hear is the kicker: Dr. Resident demands to know which nurse was giving him attitude, so that he can ask where she went to med school and what authority does she have to question his orders. Gosh golly gee, I never got her name! As a dumb nurse, it slipped my mind...

[cjcsoon2bnp, MSN, RN, NP]

I'm not sure if this counts as the "worst doctors orders ever received" but it didn't seem right to me.

In my first Med/Surg clincial I had a post op patient, the patient had a minor, same-day ENT related surgery but was hospitalized for C/O chest pain after surgery (the patient had a serious cardiac history). As the student nurse, I examined my patient and went about my duties until I was informed by the lab of a critical low lab value (K level of 2.7). The primary nurse and I discussed this and we determined that she needed to get orders to treat this low potassium level. The ENT resident came and examined the patient shortly after and said that the patient was ready to go home today. The nurse told me to notify the resident about my concerns and request an order for IV Potassium so that we could get the level up (she stood by my side but wanted to give me the chance to practice this communication skill.) I notified the resident of this mornings lab result and asked what she would like to order for us to treat this value. She said the patient was going to get PO Potassium Tablets (2 x 5 mEq tablets) and then discharge him before lunch. I wasn't sure what to say and so the nurse spoke up and asked if we could get an order for IV Potassium, the resident said it wasn't necessary. The nurse then asked if we could possibly get another K level drawn before the patient left, she said it was unnecessary and to discharge him before lunch time. The resident left and I asked the nurse what we should do. Being one of those "old school" nurses she said that the physician was making a big mistake and that she did not feel comfortable at all letting this patient leave with such a low potassium level and a cardiac history. Within the hour a GI attending came to see the patient (I can't remember why but I was glad to see him) and the nurse saw him go into the room and told me to "Watch her go get that IV Potassium". She stood at the door and as soon as he came out she asked for a moment of his time and the conversation went like this...

NURSE: "Dr. SOANDSO, I hate to bother you but I was wondering if I could run something by you about Patient SOANDSO."

Dr. SOANDSO: "No problem. What's up?"

NURSE: "Well, at 0800 the lab called to inform me of a critical lab value. The patient has a K level of 2.7. I spoke to the ENT resident when she came to examine the patient's dressing about an hour ago. She ordered 10 mEq of PO Potassium and then said the patient should be discharged before noon. I'm concerned with this patient's cardiac history and this low value that we might want to give the patient some IV Potassium and obtain another K level before the patient is discharged. What is your recommendation?"

Dr. SOANDSO: "I would feel much more comfortable with giving IV Potassium and another K level being drawn before we discharge Mr. SOANDSO. I would rather not have one of my patient's develop a hypokalemia related arrhythmia at home after we just discharged him from our care. That would be rather negligent on our part wouldn't it?

The nurse smiles and nods.

Dr. SOANDSO: "How about we do two 500 mL boluses of NS with 20 mEqs of K each can go over 3 hours and when the boluses are done we can do a repeat draw of K levels. If the levels look good then we can probably discharge him around dinner time. I think I would feel much better with that, how about you?"

NURSE: "Thank you doctor. Would you like me to notify the ENT of the updated plan?"

Dr. SOANDSO: "That's not necessary. I will be having a conversation with her myself about critical lab values and acting upon the recommendations of an experienced nurse."

I couldn't' help but smile as he left and we went and got the fluids for the patient. I always wonder what would have happened if that nurse never spoke up and said something to the other physician.

!Chris

[meyerbj81]

My newest one in the ER was a urine preg and beta hcg on a 6 year old boy. This was done by a wonderfully sweet elderly ED doc, who is brilliant with procedures(previous surgeon) and treats the nurses like gold but is a little past his prime. I politely pointed out the error to which he just laughed and stated he was pretty sure they'd both come up negative.

[wlb06]

I am just starting and saw "give purple Popsicle" by a PA, lol

[sk8rn]

Head CT on pt who had complained of nausea and near syncope during blood donation.

[sk8rn]

Not a bad order, just a slammed/sleepy PA.

On a pt's script for discharge. "0.5 mg of anxiety p.o. prn"

[murphyle, BSN, RN]

Part of my job is to return the MD's pages while he is scrubbed in. Today I returned a page and the RN on the line said, "I need to clarify an order...I am not going to do what is ordered...we need to clarify this..."

me: "...go on..."

"Dr. Resident ordered 40mEq KCl IV now."

I report to Dr. Resident who responds "K is 3.1." Well, that clears everything up!

"Is that as a push or diluted?"

"Go ahead and dilute it"

me:"...go on..."

Finally he gives the order to dilute w/ 250ccNaCl and run over 4h.

Hear is the kicker: Dr. Resident demands to know which nurse was giving him attitude, so that he can ask where she went to med school and what authority does she have to question his orders. Gosh golly gee, I never got her name! As a dumb nurse, it slipped my mind...

Had one of those when I was in school - one of my fellow SNs had a patient with a K of 3.4 who was ordered 40 mEq of KCl IV push, through a peripheral IV. (The patient was a known tough stick; all we had for IV access was a 22ga in the hand, and that was hanging on by its proverbial fingernails.) The SN questioned the order to the staff RN, who in turn questioned it to the resident, who stated in a very snappish tone that "everyone knows" that you replace 10 mEq for every 0.1 mEq/L deficit, and K of 3.4 is "obviously" an emergency requiring immediate IV replacement - but not enough of an emergency to consider placing a PICC, that would let us replace this "critically low" K level any faster.

*facepalm*

When pressed, the resident became very angry and threatened to write up the RN, the SN, the SN's instructor and anyone else within arm's reach, so the RN/SN pair just documented the situation and waited for new orders. The buck stopped with Pharmacy, who refused to fill the order (thank God they didn't stock concentrated potassium solutions in the Pyxis on that unit) and called the attending to clarify. Fifteen minutes later, we saw the resident sprinting out of the unit, looking like their career had just flashed before their eyes. See, the attending was extremely angry about being interrupted on the golf course, and once they found out who was responsible... :angthts:

[Penelope_Pitstop, BSN, RN]

Had one of those when I was in school - one of my fellow SNs had a patient with a K of 3.4 who was ordered 40 mEq of KCl IV push, through a peripheral IV. (The patient was a known tough stick; all we had for IV access was a 22ga in the hand, and that was hanging on by its proverbial fingernails.) The SN questioned the order to the staff RN, who in turn questioned it to the resident, who stated in a very snappish tone that "everyone knows" that you replace 10 mEq for every 0.1 mEq/L deficit, and K of 3.4 is "obviously" an emergency requiring immediate IV replacement - but not enough of an emergency to consider placing a PICC, that would let us replace this "critically low" K level any faster.

*facepalm*

When pressed, the resident became very angry and threatened to write up the RN, the SN, the SN's instructor and anyone else within arm's reach, so the RN/SN pair just documented the situation and waited for new orders. The buck stopped with Pharmacy, who refused to fill the order (thank God they didn't stock concentrated potassium solutions in the Pyxis on that unit) and called the attending to clarify. Fifteen minutes later, we saw the resident sprinting out of the unit, looking like their career had just flashed before their eyes. See, the attending was extremely angry about being interrupted on the golf course, and once they found out who was responsible... :angthts:

Well, I don't see a problem replacing a K of 3.4, especially if the patient is having vomiting or diarrhea, or cardiac issues. Nor do I see a problem with giving K through a peripheral. (Run slow and Y it with NSS!) I do see a problem with the order, though.

40 mEq of K IV PUSH!

[murphyle, BSN, RN]

CamaroNurse: The patient was in for diuresis r/t CHF exacerbation; they were taking Lasix at home PTA, and getting 40 mg q12h in the hospital. K-Dur 20 mEq q12h was already ordered, and the patient was stable with K levels hanging between 3.4-3.6. Given the history, we figured they'd probably been living with that low-ish K all along.

I've done K supplemental doses through a peripheral IV also (though almost always through an AC line and always in conjunction with NS or D5 1/2NS), and I've seen replacement orders for K levels in the 3.2-3.4 range. However, there are lots of less hazardous ways to manage a borderline low K like that, particularly for a stable patient who will be staying in the hospital for a while - add K to the IV maintenance fluid (i.e. D5 1/2NS +20), increase the K-Dur dose, or switch to a potassium-sparing diuretic, for examples. The resident wouldn't consider any of that, and against all reason continued to insist on a therapy that stood a very good chance of seriously harming or killing the patient. Hence, Worst Orders Ever.

[Penelope_Pitstop, BSN, RN]

CamaroNurse: The patient was in for diuresis r/t CHF exacerbation; they were taking Lasix at home PTA, and getting 40 mg q12h in the hospital. K-Dur 20 mEq q12h was already ordered, and the patient was stable with K levels hanging between 3.4-3.6. Given the history, we figured they'd probably been living with that low-ish K all along.

I've done K supplemental doses through a peripheral IV also (though almost always through an AC line and always in conjunction with NS or D5 1/2NS), and I've seen replacement orders for K levels in the 3.2-3.4 range. However, there are lots of less hazardous ways to manage a borderline low K like that, particularly for a stable patient who will be staying in the hospital for a while - add K to the IV maintenance fluid (i.e. D5 1/2NS +20), increase the K-Dur dose, or switch to a potassium-sparing diuretic, for examples. The resident wouldn't consider any of that, and against all reason continued to insist on a therapy that stood a very good chance of seriously harming or killing the patient. Hence, Worst Orders Ever.

I agree that that it was a bad order, but not for the reason you've stated.

Do you get why IV PUSH Potassium is ALWAYS a terrible order?