Welcome to Naija Nurses Forum

Register now to gain access to all of our features. Once registered and logged in, you will be able to contribute to this site by submitting your own content or replying to existing content. You'll be able to customize your profile, receive reputation points as a reward for submitting content.

Confronting Doctors with Wrong Orders

User avatar
Kunle Emmanuel
Webmaster
Webmaster
Reactions:
Posts: 1946
Joined: Mon Jan 09, 2012 5:02 pm
Location: Lagos
Contact:

Confronting Doctors with Wrong Orders

Unread post by Kunle Emmanuel » Sun Mar 12, 2017 6:33 pm

Confronting doctors can be intimidating, but we are the patient's final defense against wrong orders. Somebody has to make sure we get it right. (As always, the illustrations are the products of my imagination or names or events used in a fictitious manner. Any resemblance to actual events is purely coincidental.

Confronting Doctors with Wrong Orders
We are standing at the counter of the nurse’s station in the ER when I tell Dr. Hanson that his patient in 18 is asking for pain medication.
“There’s nothing wrong with her,” he retorts. “She’s just full of BS.”
“If there’s nothing wrong with her, and she’s just full of BS, why are doing $8,000 worth of tests?” I ask bluntly. “Maybe we should give her some pain medication just in case.”

When Dr. Hanson slides back into the doc box to order some morphine, another nurse who had overheard the exchange nudges my arm to get my attention. She half whispers, “I like the way that went down.” I hadn’t given the exchange a second thought while it was happening, but, based on her comment, it occurs to me that I’d just done something she would have found hard to do. It may be easier for me to confront doctors because I’m older than a lot of them and worked here longer than most of them. Also, in the ER, we are used to working alongside different classes of providers, interacting on a casual level that might feel uncomfortable to nurses in other departments. Admittedly, I am writing from an ER perspective. But, even if you are relatively young, new, or intimidated for any other reason, there are three times nurses must be assertive enough to speak up.

First, we need to confront providers when their orders don’t make sense or demonstrate a clear mismatch to a patient’s individual situation. In the era of point and click, entire panels of orders are quickly entered. Sometimes the entire set is intended for another patient. Or maybe the doctor fails to remove a fluid bolus from a panel ordered on a potentially septic patient who is also showing signs of acute CHF. Maybe a provider orders an x-ray on the wrong hip, or omits a Digoxin level on a patient with symptoms of toxicity, or orders antibiotics without ordering the usual blood cultures. These simple, potential, or even obvious oversights are easy to confront because we’re “just checking” without questioning judgement. It’s an easy question: “Hey, I just wanted to double check. Do you want any blood cultures before we start the Rocephin?”

The second level is a slightly harder conversation. But when there appears to be clear judgement error, we still need to ask. For example, an 87-year-old with multiple system failures comes in via EMS. He is crashing, and we intubate him on arrival. The workup shows he needs immediate surgery to remove a large intra-abdominal abscess. But, when the family shows up, we learn that the patient has an Advance Directive and doesn’t want any heroic measures. He probably would have refused intubation if he had been alert enough to express himself. The surgeon evaluates the patient and states that he will not survive the surgery. The family decides to have him extubated and go to comfort measures only. The daughter specifically asks, “But you won’t do anything to make him die quicker, will you?” Dr. Stone assures her that we will not.

Dr. Stone and the surgeon spend several more minutes discussing the case with the family while the respiratory therapist removes the ET tube, and the patient starts breathing on his own again. As Dr. Stone walks away, he says, “We can restart Fentanyl drip.” The Fentanyl drip was held along with the Diprivan due to low blood pressure prior to the decision to extubate the patient. It was running at 300 mics/hour. I ask Dr. Stone, “Are you sure you want to restart it? You just told the daughter we wouldn’t do anything proactive to cause his death.” He replies that it will be okay and turns to walk away. I just questioned his judgement, and he confirmed his intention.
Now we hit level three. It gets more challenging when we have already questioned a doctor’s judgement once, but he persists in following a course we cannot condone. Continuing the case above, I follow the doctor toward the doc box. I’m not belligerent, but I can’t let this go. “Dr. Stone, at the very least I’m going to need you to enter a new order, and I’ll have to chart we had this conversation just in case we all end up in court together trying to explain why we ran Fentanyl at a rate that stopped this guy from breathing right after you assured the daughter we wouldn’t do anything to hasten his death.” He stops on a dime, whirls back toward me, slaps himself on the forehead, and says, “I forgot we just extubated him. Good catch.” They can be very good. They are not gods. Sometimes the third level is essential.

If we get to level three, a second or third opinion may help bolster courage before going back for the decisive confrontation. For example, there is an order for a bolus of Integrilin which is well over the standard protocol dose. I question the doctor, and he confirms the dose. But he is looking at an x-ray, and I have a feeling I don’t have his full attention. I double check the order in the computer, pull the medication from the Pyxis, and turn to another seasoned RN in the med room. I hold up the bottles and show her that the order for the bolus alone grossly exceeds the volume in the large bottle for the total infusion. We look at each other and say in unison, “No way.” Emboldened by her confirmation, I go back to the doctor with both bottles in my hands. I get his complete attention and show him the bottles, explaining the usual dose compared to his current order. He checks again and finds that he is off by two decimal places, accidentally ordering 100 times his intended dose. Oops.

A friend gave me a t-shirt years ago. It is threadbare now, and the slogan is hardly readable. But it has generated some interesting comments and stories through the years: “Be kind to nurses. We keep doctors from accidentally killing you.” It’s true. We are it. We are the patient’s final defense in the delivery of most healthcare, and we must have the courage to confront other providers on whatever level is necessary to make sure we all get it right.

by RobbiRN, RN Pro


Nigerian Nurses lighting up the world one candle at a time.

User avatar
Kunle Emmanuel
Webmaster
Webmaster
Reactions:
Posts: 1946
Joined: Mon Jan 09, 2012 5:02 pm
Location: Lagos
Contact:

Re: Confronting Doctors with Wrong Orders

Unread post by Kunle Emmanuel » Fri Mar 17, 2017 11:48 am

Bulama Bukar
I agree.its a lot easier for an older,more experienced nurses to not only spot wrong order but emphatically demand or suggest better alternative.
Dorothy Edo All the nurses must be brave to stand up for what they know is right no matter the age or years of experience. This will always benefit the clients and save us from litigations.
Toluwabori Odunewu Morakinyo This reminds me of an occurrence about 15years ago. I was working on the paediatric ward and an outrageous dose was prescribed for a 2yr old. I drew the attention of my matron to it but she felt that the doctor couldn't be wrong. I tactically delayed the administration of the drug until the doctor came back to the ward (I knew he was still around), I showed him my own calculation and asked the method of calculation he used to arrive at the particular dose he ordered; he then discovered that he had erred in calculation. He thanked me profusely.

Lesson - a young nurse can still be assertive.
Chichi Asagwara This is awesome! Thanks
Chichi Asagwara You know what it boils down to? A nurse knowing her onions and being assertive. Like the poster said, we are the patient's last line of defense. Let's keep reading. Studying. Researching.

I always carry my cell phone in my pocket while passing Meds so I can do a quick check to confirm a particular medication indication and other parameters.
Ahaiwe Victor C Eye opener. However, only nurses who know their right from their left can stand to do this. Nurses of this generation barely study.
Stephanie Nwemere Knowledge is power, that is more reason why we nurses should be reading voraciously, this will enable us to defend whatever correction we are giving. Thanks a lot dear
Celine Uwalaka It is only what you know you can correct, and always correct with love not the you don't know it stuff or correcting with arrogance remember life is involved here.
Aliyu Garba Nursing is a dynamic profession therefore "must read" is the answer to catch up with daily practice
Nigerian Nurses lighting up the world one candle at a time.

User avatar
Kunle Emmanuel
Webmaster
Webmaster
Reactions:
Posts: 1946
Joined: Mon Jan 09, 2012 5:02 pm
Location: Lagos
Contact:

Re: Confronting Doctors with Wrong Orders

Unread post by Kunle Emmanuel » Fri Mar 17, 2017 11:52 am

Benja Osolife Uduka A Nurse can only question a doctor's order if he/she is knowledgeable.
The schools producing different cadres of Nurses in Nigeria have failed us.
During my school days we had students who believe Pharmacology is a Masculine course.

Many Nigerian Nurses shy away from Pharmacology. I don't know why... How can such a Nurse question a doctor's prescription?Coupled with the fact that many Nigerian Nurses treat doctors as demigods, young and old Nurses alike.
Aladesawe Rahmat Now it is a must to know your onion in pharmacology. Cos my school of though is so crazy about every course.
Aladesawe Rahmat Most of the time. We don't get backed up by our superior colleagues.... N at the end of the day we feel like a fool when you correct the emotionally unstable one.
Yahaya Abdullahi One of the fundamental duties of the nurse is "advocacy" do it right and intellectually.
Nigerian Nurses lighting up the world one candle at a time.

jackroger368
Reactions:
Posts: 4
Joined: Mon Aug 21, 2017 6:26 am

Re: Confronting Doctors with Wrong Orders

Unread post by jackroger368 » Mon Aug 21, 2017 6:34 am

In my twenties I would be doubtful of an awful hair style, yet once you turn thirty it's more about whether he a decent individual and does he open the entryway for me. When you turn thirty-five, it's more about would he make a decent father. What's more, Do my Dissertation regardless of the possibility that you're simply enjoying some person and burrowing on somebody, I figure you can't resist the urge to think in those terms. You can demonstrate that thankfulness in huge and little ways. It's regularly the easily overlooked details that truly check and will mean a steady, cherishing, and commonly gainful relationship. I truly like your post, much esteemed.

Post Reply Previous topicNext topic

Social Media

       
  • Similar Topics
    Replies
    Views
    Last post

Who is online

Users browsing this forum: No registered users and 8 guests