'Confronting Doctors with Wrong Orders'

[W19]

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http://allnurses.com/general-nursing-discussion/confronting-doctors-with-1093333.html

Oh boy!

 

[Ismet]

I'm going to step in here before the discussion starts to say that bashing other professions is not tolerated on the forums. If you can contribute to the discussion professionally, then go ahead.

I appreciate when a nurse double checks something I've ordered. We are not immune to making mistakes and nurses have caught those mistakes. However, what the article doesn't address is that the flipside is true too. I've caught nursing errors, I've had to talk to nurses about actually documenting I&Os or to remind them about something I ordered and they missed or forgot to do. It goes both ways, both sides need to have each others' backs, both catch errors the other makes, and both keep each other from harming patients.

I don't appreciate the few times a nurse has spoken down to me since I'm an intern, but still appreciate the double check on something. Instead of saying "you didn't order enough ibuprofen for this kid" they could have said "hey I saw you ordered x mg ibuprofen, just wanted to double check that's what you wanted." Turns out I had ordered the correct amount in mg/kg but the way it popped up in their chart they thought it was mg. Honest mistake, appreciated the double check in that situation, but could have done without the accusation.

 

[Noisewater-TDX]

Wrong orders do get put in and it's the RNs job to verify whether or not these are safe for the patient. I've done it countless times. Demanding a med for a patient is a little much but I have questioned why we aren't giving anxiolytics or opiates to patients that are in obvious need of something. Suffering is bad m'kay? lol

 

[cherubb3]

I was a nurse before going to medical school and I can tell you that this is considered standard for nursing practice. No one is perfect, and it is safest for everyone on the team to be on the same page. If an order made absolutely no sense to me I would ask about it, not because I didn't agree but because I wanted to make sure there wasn't an error. It was rare, but it did happen.

 

[67552931811]

Nothing to see here:

 

[Perrotfish]

http://allnurses.com/general-nursing-discussion/confronting-doctors-with-1093333.html

Oh boy!

The article seems like an appropriate, professional piece about exactly what you want a nurse to do. If they see something weird in the orders they ask if you meant to do that. If necessary they ask twice.

Now as residents it's a little more complicated/frustrating, because very often when you have confirmed an order that a nurse disagrees with they feel that the next step is not to ask you twice, but rather to call your senior or attending. On the one hand, that can keep patients safe from a bad resident. On the other hand can be used to bully you into bad care that's more convenient for the nurse, because when attendings get woken up at 2 a.m. due to a nursing concern they're going to direct their anger at the resident rather than the nurse. The classic examples is the night nurse who wants you to snow a patient who you are trying to wean from pain meds, because it means a happy/quiet patient. That's when you really need to learn to pick your battles.

But even that isn't bad nursing care. Bad nursing care is when they don't follow orders, or worse yet when they start doing things without order. As long as they ultimately follow the order, even if they express suggestions/concerns before carrying it out, they are doing the job you want them to do.

 

[Tenk]

So hate to burst your popcorn bubble but as an ED attending most everything in that article is pretty damn true and accurate. Love it when my ED nurses catch my errors or ask for clarification. I try to create an environment in my department where they know they can come to me with any questions or clarifications. This is the way it should be done because otherwise they will keep their mouth shut at both your and the patient's expense.

 

[Lawpy]

I'm going to step in here before the discussion starts to say that bashing other professions is not tolerated on the forums. If you can contribute to the discussion professionally, then go ahead.

I appreciate when a nurse double checks something I've ordered. We are not immune to making mistakes and nurses have caught those mistakes. However, what the article doesn't address is that the flipside is true too. I've caught nursing errors, I've had to talk to nurses about actually documenting I&Os or to remind them about something I ordered and they missed or forgot to do. It goes both ways, both sides need to have each others' backs, both catch errors the other makes, and both keep each other from harming patients.

I don't appreciate the few times a nurse has spoken down to me since I'm an intern, but still appreciate the double check on something. Instead of saying "you didn't order enough ibuprofen for this kid" they could have said "hey I saw you ordered x mg ibuprofen, just wanted to double check that's what you wanted." Turns out I had ordered the correct amount in mg/kg but the way it popped up in their chart they thought it was mg. Honest mistake, appreciated the double check in that situation, but could have done without the accusation.

So hate to burst your popcorn bubble but as an ED attending most everything in that article is pretty damn true and accurate. Love it when my ED nurses catch my errors or ask for clarification. I try to create an environment in my department where they know they can come to me with any questions or clarifications. This is the way it should be done because otherwise they will keep their mouth shut at both your and the patient's expense.

Well these are useful posts that contradict the usual controversy common in these forums. Goes to show the critical importance of working in a collaborative and team-based environment.

 

[kamakazi5]

Pretty good article overall, thanks for posting!

 

[dadaddadaBATMAN]

Wrong orders do get put in and it's the RNs job to verify whether or not these are safe for the patient. I've done it countless times. Demanding a med for a patient is a little much but I have questioned why we aren't giving anxiolytics or opiates to patients that are in obvious need of something. Suffering is bad m'kay? lol

I loved this until the bit about opiates and anxiolytics. Those are the groups of drugs that I regularly see misused by well meaning people (and occasionally lazy ones). Especially benzos.

Suffering is bad, delerium is worse.

 

[libertyyne]

This is taught during orientation to every healthcare worker in my organization. There are different techniques taught on how to escalate concerns. This is a reasonable article rather than the "oh boy" .

 

[Mad Jack]

If I put in an order that looks wrong, I hope somebody is putting a second set of eyes on it. Especially with electronic systems, it's easy to just click the wrong thing and then your patient is getting something ridiculous.

Like, as an RT, I'd get orders to give my patients PO Mucomyst all the time. Or IV epinephrine. Or the wrong concentration of albuterol. So I'd just be like, hey, dude, I think you clicked the wrong thing. And they'd fix it, and everyone was happy.

 

[ProfMD]

At my place, we work pretty hard to make sure nurses (or anyone else for that matter) feel that they can speak up. We also make sure they understand that they can elevate concerns. That way, if the resident does something that looks weird and the nurse does not feel they got a satisfactory response from the resident, they will call the attending.

It's all about patient safety and optimum care, not physician ego.

 

[libertyyne]

Here is the pertinent information from "Critical Care Handbook of the Massachusetts General Hospital"https://books.google.com/books?id=o...age&q=escalating concerns in cockpit&f=false

 

[ProfMD]

Here is the pertinent information from "Critical Care Handbook of the Massachusetts General Hospital"https://books.google.com/books?id=oW-9CgAAQBAJ&pg=PT842&lpg=PT842&dq=escalating+concerns+in++cockpit&source=bl&ots=kXNtONAFuA&sig=YhBegO0rScVTEmtODhCRZmzNnk4&hl=en&sa=X&ved=0ahUKEwipgvqTwNPSAhXqy4MKHVbHCA4Q6AEIPzAH#v=onepage&q=escalating concerns in cockpit&f=false
View attachment 216146

We take a similar approach. In addition to making sure nurses feel comfortable raising concerns, we also train people how to raise those concerns. Key is to succinct, accurate, and polite when raising concerns.

 

[Noisewater-TDX]

I loved this until the bit about opiates and anxiolytics. Those are the groups of drugs that I regularly see misused by well meaning people (and occasionally lazy ones). Especially benzos.

Suffering is bad, delerium is worse.

I work in the ER now. The docs seem to be on a razors edge over these meds. Either we give tons of them, or none.

One patient gets ketorolac and norflex, the other gets diluadid and Valium. I'm not sure what type of doc I'm gonna be yet, I just don't want my pts to suffer...

And I don't want to get played for drugs either lol.

But I get what your saying, they can be overused. Especially on floors at night mostly.

 

[IlDestriero]

Our orders get screened by a pharmacist prior to release and then by the Nurse in the PreOp/PACU who is going to administer it. I'm happy with that. I'm also open to the nurses in the trenches asking for additional opiates, Valium, anti nausea meds, etc. It's a team. I may decline their request, but I welcome it and will give it due consideration.


--
Il Destriero

 

[Psai]

I actually like it when a nurse questions orders because a lot of the time they catch something wrong or bring up a valid point. There are a handful of nurses that were just bad and either ignored the order with a negative effect on the patient or questioned an order without knowing what the hell they were talking about but talked down to me as if they did. One example is in the title of the article "confronting doctors" instead of "questioning doctors" or "advocating for the patient". But their comments section was pretty good in addressing that and it seems like they have a lot of good people on their site.

It's really a shame how all the health care fields are building an us vs them mentality in their practitioners. Some people only care about being a team when it benefits them.

 

[libertyyne]

I actually like it when a nurse questions orders because a lot of the time they catch something wrong or bring up a valid point. There are a handful of nurses that were just bad and either ignored the order with a negative effect on the patient or questioned an order without knowing what the hell they were talking about but talked down to me as if they did. One example is in the title of the article "confronting doctors" instead of "questioning doctors" or "advocating for the patient". But their comments section was pretty good in addressing that and it seems like they have a lot of good people on their site.

It's really a shame how all the health care fields are building an us vs them mentality in their practitioners. Some people only care about being a team when it benefits them.

I feel like we need more physician administrators. Currently a large portion of administration is filled with nurses and it definitely leads to this only care about being a team when it benefits nursing or the administration.

 

[hello1234!]

When a nurse calls me with a clarification question or something to add that I may have missed, I always make the effort to thank them. However, I didn't get many of these calls when I did inpatient because if there was a change in plan, such as switching from iv to oral pain meds, I always called the nurse to let them know. Also, when I was doing ICU I made rounds before the nurse shift change asking if any of the nurses neeeded anything. This really helped in decreasing pages for things like restraint orders and didn't really take to much time to do.