Wow. Just wow

BrandonLPN, LPN · Mar 4, 2015

There is a huge difference between giving a med in an emergency and getting the order later to save a life and deliberately practicing outside your scope in a non emergent situation.

It still depends on what you are specifically talking about here.

When I worked at the jail I would sometimes give inmates Motrin before getting an order. Clearly, these were not emergent, "life-saving scenarios". You could argue that I was practicing outside my scope, I guess. No one really cared, including our doctor. He just wasn't a fan of standing orders. He probably signed dozens of "after the fact" medication orders without batting an eyelash every day.

In LTC I will, on occasion, knowingly give a med well outside of it's scheduled time, if the situation calls for it and common sense dictates it poses no danger. I have a resident who will, once in a blue moon,wake up at 2 or 3 am and decide it is time to get up and sit in the dinning room. On those nights he wants me to give him his 6am synthroid. Sure, why not? Technically out of compliance, technically a "med error". But there's no harm. Its only slightly out of synch with the time he took it the day before. And the doctor would think me an idiot if I wasted his time by calling him or by trying to get some elaborate, confusing "May take at 2am if he wishes" order.

BrandonLPN, LPN · Mar 4, 2015

Callitor you are correct, but there is sooooo much more to the story.

Not to sound rude, but unless we know what you're talking about, part of me is inclined to assume you might be overreacting.

TexMex22 · Mar 4, 2015

I'm really at a lost for words. A nurse deliberately made a med error. When she was notified by the nurse that caught the error that an incident report will be made, she had a resident write the order to cover her. Now a patient is retrieving a medication that is not indicated or needed. No harm done to patient, but it is just sad that some nurses are able to get away with this type of behavior.

Do you mean "receiving" â€¦.

And if you know this to be true (that the medication is not indicated) you have an obligation to report this. Otherwise, aren't you complicit in allowing a patient to receive an unneeded medication?

PG2018 · Mar 4, 2015

Technically, I see this all the time. For example, a patient becomes nauseated. The nurse retrieves ondansetron from the Pyxis and administers it IVP. The nurse enters the order into a computer under whichever doctor was covering the patient. The nurse informs the doc in passing (or not), and the doc signs off. Insert another med. I've even seen nurses be so brash as to do the same with scheduled meds.

And by scheduled, I mean controlled. i.e. schedules II-V.

Mavrick, BSN, RN · Mar 4, 2015

There are times giving a med and getting the order after is appropriate and we are expected to use critical thinking and known standard protocols to make the determination. Also, if you have a very good, long standing relationship with the doc you often know what they will or won't want done. Can you be more specific?

I agree here. Without knowing a lot more about the situation (assessment) I can hardly make a determination (diagnosis) about what would be the appropriate action (intervention).

At this point, could range from an excellent example of collaborative practice to a violation of Nurse Practice Act to criminal charges.

Gooselady, BSN, RN · Mar 4, 2015

Technically, I see this all the time. For example, a patient becomes nauseated. The nurse retrieves ondansetron from the Pyxis and administers it IVP. The nurse enters the order into a computer under whichever doctor was covering the patient. The nurse informs the doc in passing (or not), and the doc signs off. Insert another med. I've even seen nurses be so brash as to do the same with scheduled meds.
And by scheduled, I mean controlled. i.e. schedules II-V.

Wow!

That takes balls! But I can totally see how this would work just fine with long term staff with long term trusting relationships. Several of our oncologists gave us tacit 'permission' to use our best judgment with late admissions, when he/she forgot to add the Flonase or nightly statin the patient has been taking forever. Mostly though, we had tacit permission to order labs like CXR and ECG, UA C&S etc. Even this is completely 'illegal' but was OK for the sake of patient convenience, especially late at night or in an emergent situation. It was a private affair, between the nurse and the doctor and even then considered risky and many nurses (especially newer nurses or newer employee nurses) wouldn't dream of ordering a UA without calling for the order.

As for the OP, I feel sort of compelled to flat out agree and commiserate because of how the OP was worded. And I resist tacit 'compelling' as rule . . . so in terms of how lacking information IS in the original post, I need more information before I agree or disagree.

When I see "there is sooooooo much more to this" I have to wonder why at least some of this soooooo much more isn't included so that I even can agree and commiserate. I mean no offense to the OP at all :) just a mild criticism of how the original post is worded and how we're tacitly expected to agree rather than make our own minds up :)

jadelpn, LPN, EMT-B · Mar 4, 2015

There are nurses who hold meds due to whatever parameters they see fit as well.

I can see a scenario where the nurse in question gave the wrong med to the wrong patient, and now is attempting to cover with an order--an antibiotic, or daily aspirin or something of that nature--and now this patient either has a 10 day course of antibiotic or some other drug that is for heart health or vitamin...

I really don't know the details, however, you do not either, unless you are the charge nurse who had discussion with this nurse regarding a write up. And there are MD's who give huge leeway to nurses as to not be disturbed at 2am regarding Tylenol. OR taken from their office patients to discuss the merits of continuing home meds when they were not ordered on admission.

Unless you are in a charge position and HAVE to deal with it, I would stay completely out of this situation. Completely. How another nurse practices is not under your control. Just be mindful and careful if you have to take a patient from the nurse. Otherwise, to rush to judgment is never a good thing--and I would take the high road on this one.

dinah77, ADN · Mar 4, 2015

IF the doctor agreed to order it after the fact, can it really be that bad or dramatic?

I can't see any doc agreeing to cover a mistake such as an anti-coug, narc or something else serious after the fact

kbrn2002, ADN, RN · Mar 4, 2015

I understand that you really don't want to go into great detail here, but this could be really no big deal. I have no problem starting a prn OTC order if it's not contraindicated and having our rounding sign off later. I'll get a UA if a resident is symptomatic and get the order a little later too. It gives that much more time for the C & S to get back so the appropriate abx can be started sooner. I have started orders on a new admit that they've been taking forever but that didn't get transcribed to the discharge orders from the hospital, this is amazingly not at all uncommon. There could be many instances where a nurse would feel comfortable initiating a new order and the MD would feel just as comfortable signing off later.

dishes, BSN, RN · Mar 4, 2015

When a patient has a new medication ordered they should be aware of why it was ordered, the risks and the benefits. Medications that are seemingly innocuous have caused adverse events and it is unethical to expose a patient to unnecessary risk, unless the benefit outweighs the risk. If there wasn't an obvious medical reason documented for giving the medication, I would speak to the ordering physician and ask what the medical reason is for the medication and if the patient was informed, if yes, I would ask that they document it, if no, I would ask that the medication be discontinued.

classicdame, MSN, EdD · Mar 4, 2015

at the very least, the times on the order and the administration should differ. That would indicate she was practicing medicine without a license. I would notify the BON.

allnurses Guide · Mar 4, 2015

Wow. Just wow.

We still don't have much info to go on here so I won't tell you to report her to the BON.

Maybe I've just worked hospice for too long but I use my nursing judgment and do things for patients, meds and otherwise, and then inform the doc.

Of course we are allowed to titrate things like Morphine Sulfate and Dilaudid and I can start a F/C if the need presents.

I really wish there were more details here.