Would you question a preceptor...or a doctor?

umbdude, MSN, APRN · Dec 16, 2016

As a new nurse, I would ask seasoned nurses if I ever have these types of questions. I don't think it's uncommon for doctors prescribe meds that could interact with each other, but they and pharmacists have more in-depth knowledge about these meds than what's written on the labels (e.g. the probability of it happening and at what dosages) and they know the risk/benefits of doing so. Obviously, there are some meds that have obvious and dangerous reactions if combined with other meds (e.g. MAOIs), and in that case I would hold and question.

As a student, you should always ask your preceptor before administering anything that you question. My preceptor had to be present at all time and he welcomed questions. In fact, if you just admin without asking you would come across as unsafe or that you had no clue that the drug might be dangerous.

verene, MSN · Dec 16, 2016

As a CNA and nursing student there have already been a couple times where I've questioned orders. "Hey noticed this patient is on X and Y, when I was doing patient prep last night it looks like there are some serious interaction risks between these to drugs, would you mind explaining the rational for why the benefits out way the harm for this patient? I'd like to better understand how these medications are used."

Typically I went to my nurse first and then the pharmacist (because they were more accessible) but I've also talked to providers. Most are more than willing to educate a nursing student on their thoughts, and going through the rational with me causes them to also think through the order again. Many times there are good reasons for the patient to be on both, or at the dosage levels being prescribed the risks are minimal. Other times, not so much.

I recently has a situation during clinical where I noticed one of the patient's home medications would interact with a new order from the provider and was able to work through the whole process of confirming the new order with the provider, talking to the patient about why NOT to take the home medication for the next 2 weeks until the new medication had finished it's course, and how the medications worked, why they would interact, and the possible consequences of that interaction, and on the provider's orders made recommendations of another OTC medication that could be safely used in place of the normal home medication if need arose. I ran through everything with my RN for the day first before taking to provider and patient, but I'm really glad I had the experience, and that I actually had retained enough from pharmacology class to notice and be comfortable explaining to the patient.

As a nurses it will be our responsibility to question orders that don't make sense. In my pharmacology classes it has been repeatedly emphasized that nurses are the "last line of defense" for our patients when it comes to medications. We need to know the drugs they are taking, why they are taking them, the typical dose ranges of those drugs, the appropriate dose for this particular patient, how they work in the body, and any potential interaction and side-effects and the s/s of those interactions and side effects. If something doesn't seem right we need to question it. Many times it may still be okay to give once double-checking with provider and/or pharmacist but always thinking things through and questioning orders that don't make sense can save patients. We as nurses should also be providing education to patients as to possible side effects and interactions between their medications, what they need to look for, what is an expected and non-worrisome interaction or side effect and what signs indicate that they should contact their provider right away.

AceOfHearts<3 · Dec 16, 2016

Always research and question something you don't understand! I utilize pharmacists as much as I can. We have one that typically sits at a computer on my unit and I always pop by and ask them my questions. I've also questioned providers before- just the other day I asked why I had a patient on IV fluids that had also been given IVP lasix for being fluid overloaded (a question I asked in morning report and the off going nurse didn't know).

Months ago I prevented a med error by questioning the pharmacist. The pharmacist had approved a med and it had arrived for me to administer, but I had questions about it first. The doctor had actually selected the wrong route and the pharmacist didn't initially catch it either- it wasn't until I questioned it.

Just a week or two ago I had a patient with CKD and poor creatinine clearance who was prescribed Lovenox instead of Heparin for DVT prevention. It made me nervous and I questioned the pharmacist about it. The pharmacist reviewed the patient's file again and said I was right, the CrCl was too poor and they should be on Heparin instead. The provider and pharmacist didn't catch it and 2 other nurses who had administered it the two times before me hadn't either. Later I was talking with another nurse/friend on my unit and she didn't even realize Lovenox can be contraindicated in patients with poor renal function.

This is an interesting article that explains heparin (UFH) vs lovenox (LMWH) very well The heparins: all a nephrologist should know

In renal failure, the elimination half-life of all LMWHs is significantly prolonged. Thus, severe and even fatal bleeding complications have been reported after unadjusted dosing [4â€“8]. Although the use of these agents is not strictly contraindicated in patients with advanced renal failure, there are currently no data indicating superior efficacy and safety compared with UFH.

LMWHs with their reduced polysaccharide chain length have superior pharmacokinetic properties compared with UFH in patients with normal renal function. Following subcutaneous application, the bioavailability reaches 100% even at low absolute doses, with a longer dose-independent elimination half-life compared with UFH. Due to less unspecific binding to platelets, endothelial cells, macrophages and osteoblasts, there is a lower incidence of side effects such as HIT-II or osteopenia after chronic use. The main pharmacological limitation is that LMWHs are principally cleared by the renal route, and that their biological half-life is prolonged in patients with renal failure.

Most pharmacokinetic studies show a positive correlation between the anti-factor Xa effect of LMWHs and the creatinine clearance [23,24]. In a post hoc analysis of the TIMI 11A study (Thrombolysis in Myocardial Infarction), the creatinine clearance emerged as the most important determinant of heparin clearance, elimination pharmacokinetics and anti-factor Xa activity of enoxaparin [25].

dbabz · Dec 17, 2016

Thank you all so much for your replies. I absolutely agree that we are the last line of defense and it's something that I take very seriously. I've only been at two clinical sites so far. At the first, I never saw a pharmacist and rarely a doctor. The most recent had at least one pharmacist around most of the time. I'll be using them as a resource going forward.

dbabz · Dec 17, 2016

Wow! Good on you! Just wondering, what resources do you use to stay current on this kind of information?

Esme12, ASN, BSN, RN · Dec 17, 2016

On NPR this morning, there was an interview with two reporters from the Chicago Tribune who did an investigative piece about pharmacies filling prescriptions for drugs that have potential adverse interactions. The authors presented the pharmacies with prescriptions written by the same doctor at the same time and in many cases (sometimes over 60%) they were not warned of adverse effects of the interactions by the pharmacist, nor was the prescriber contacted.
My question is this: would you, as a nurse, question a doctor's order if you had concerns about interactions? As a student, I've had similar situations arise (not this exact one) and I'd really appreciate any input you all could add.

As a student it is not your responsibility to question the MD/PA/hospitalist/PCP. If you have a question you should follow a a chain of command...your nursing instructor who will talk to the nurse who will, IF INDICATED, notify the MD.

As a nurse I will (and have) questioned the MD/PA/NP/hospitalist/PCP if I felt a drug was potentially harmful or a wrong dose. What you probably heard on NPR is about the laws that govern pharmacies and pharmacists that they have a duty to report to the patient the use of the drug you are talking, the side effects, food interactions et al.

Illinois: Summary of Important Pharmacy Related Rules, Regulations, Statutes, and Practices That Apply to Practice of Pharmacy | Pharmacy Law—Examination and Board Review | AccessPharmacy | McGraw-Hill Medical

Esme12, ASN, BSN, RN · Dec 17, 2016

Wow! Good on you! Just wondering, what resources do you use to stay current on this kind of information?

You look everything up. Whatever is outside of the hospital you are under NO OBLIGATION to "keep up" with that information. If you are curious Google is your friend. THere are many apps for our phone that are helpful for a nurse to look up meds. Never give a drug you don't know until you look it up.

Buyer beware, BSN · Dec 23, 2016

Lawyer:

So did you question the doctor about the potential life threatening adverse reaction in combining the two drugs.

Nurse:

No sir, I figured he knew what he was doing and besides he doesn't like to be questioned.

Lawyer:

Did you know at that time that it could be dangerous to combine these drugs.

Nurse:

Yes sir, I recently read about this serious interaction in my recent CEU "drug combinations that can kill."

Lawyer:

But knowing this information at the time you still felt that it was better to avoid confrontation with the doctor so you killed the patient.

Defense attorney:

Objection your honor!

Judge:

On what grounds?

Defense lawyer:

This nurse was merely trying to foster good relations between nurses and doctors as they relate to good patient satisfaction scores.

Judge:

Good one! Continue.

AliNajaCat · Dec 23, 2016

I have a client now who was a bio major in college and has heterotopic ossification after a trauma that included a bunch of fractures. They gave her indomethacin for the HO, because it decreases calcium deposition in HO. When she asked if that might have some influence on her healing fractures, they backpedaled, ummm-er-ahh-we'll-get-back-to-you-on-that.

(Short answer: Of COURSE it would impede healing her fractures. NEVER assume that MDs know it all.)

SopranoKris, MSN, RN, NP · Dec 25, 2016

On NPR this morning, there was an interview with two reporters from the Chicago Tribune who did an investigative piece about pharmacies filling prescriptions for drugs that have potential adverse interactions. The authors presented the pharmacies with prescriptions written by the same doctor at the same time and in many cases (sometimes over 60%) they were not warned of adverse effects of the interactions by the pharmacist, nor was the prescriber contacted.
My question is this: would you, as a nurse, question a doctor's order if you had concerns about interactions? As a student, I've had similar situations arise (not this exact one) and I'd really appreciate any input you all could add.

As an ICU nurse, I have to question orders quite frequently. We're a teaching hospital and we have lots of new residents doing their critical care rotations in our unit. There are many times where I have to contact the junior resident who issued ventilator settings that do not make sense for the pt's condition, or they've prescribed a particular medication in a dose that is not appropriate. Most of the time, I can simply call the junior resident and we have a little chat. Most of the time, they understand my concerns and consult with their senior resident and make changes. I've had a few instances where they didn't want to budge and had to speak with the senior resident myself when I felt strongly that there was a potential for harm.

As nurses, we need to be able to advocate for our patients. It doesn't mean I question every single order that comes my way. However, when I do need to voice concerns, I always research my thought process before speaking with the resident. Sometimes, it's simply the resident omitted something that needed to be done (e.g. ABG follow up on a vented/intubated pt).

Depending on the culture in your institution, your concerns may be well received or they might not be. I typically document, just to make sure my concerns are noted. For example, I might make a note stating "received order to change pt's vent settings to X X X X. Called resident to clarify orders". That way, I'm not throwing the doctor under the bus with my notes, but it is clear that I sought further clarification and took action. I'll follow it up with an additional note to confirm changes or state no changes to existing order. That way, both my actions and the doctor's actions are clearly documented.

As for pharmacy, your institution's pharmacy should be reviewing all meds prescribed to the pt during their stay for any potential interactions. I know our EMR system will display drug interaction warnings if the meds prescribed haven't been reviewed by the pharmacist. We have to get an over-ride to administer without the review.

It's better to ask a question up front than blindly follow an order without considering the consequence. Patient safety comes first!

Kuriin, BSN, RN · Dec 25, 2016

Like SopranoKris, our hospital utilitizes the pharmacist quite a bit in that they are the ones who look for any drug-drug interactions or if something may be prescribed too low or too high. It is always a good idea though if you don't know what a drug is, is to look it up in your drug manual at your facility or even call the pharmacy themselves. They are a wonderful resource.