When Nurse ignores your orders
Started by quickfeet
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Remind them.
Then ask them why they aren't being implemented. Often it's a legitimate reason, often it's total BS, sometimes it is a nurse education issue. If it's a legitimate reason, perhaps the order can be adjusted. If it's a nurse education issue, explaining your reasoning is frequently sufficient. If it's BS... decide how much you want to push depending on the specific order.
If still isn't getting done, talk to the charge nurse, framing it as a potential process issue that could be improved on.
Unless it is imminently harmful to the patient, I drop it after this point. If it's something that actually harms my patient, then I bring it up with administration on the medical side and let them worry about pushing it forward on the nursing side.
Then ask them why they aren't being implemented. Often it's a legitimate reason, often it's total BS, sometimes it is a nurse education issue. If it's a legitimate reason, perhaps the order can be adjusted. If it's a nurse education issue, explaining your reasoning is frequently sufficient. If it's BS... decide how much you want to push depending on the specific order.
If still isn't getting done, talk to the charge nurse, framing it as a potential process issue that could be improved on.
Unless it is imminently harmful to the patient, I drop it after this point. If it's something that actually harms my patient, then I bring it up with administration on the medical side and let them worry about pushing it forward on the nursing side.
I generally agree with @Raryn on this.
"Hey, I ordered X on Mr. Jones in 228 and noticed you acknowledged the order but haven't done anything about it. Anything else you need from me before that gets done?"
If it's a true patient safety issue, go straight to charge RN, AOD and your attending. Otherwise, no need to make a mountain out of a molehill.
But, unless it's a "oh yeah, I saw that and then Mrs. Smith in 229 coded and I've been dealing with that ever since" issue, be sure to use whatever "Patient Safety Report" system your hospital uses to document the issue. This isn't to get someone in trouble, it's to document the problem and cover your own ass.
"Hey, I ordered X on Mr. Jones in 228 and noticed you acknowledged the order but haven't done anything about it. Anything else you need from me before that gets done?"
If it's a true patient safety issue, go straight to charge RN, AOD and your attending. Otherwise, no need to make a mountain out of a molehill.
But, unless it's a "oh yeah, I saw that and then Mrs. Smith in 229 coded and I've been dealing with that ever since" issue, be sure to use whatever "Patient Safety Report" system your hospital uses to document the issue. This isn't to get someone in trouble, it's to document the problem and cover your own ass.
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This should never be acceptable. The nurse in question should be summarily fired. Her/his job is not to deem any orders necessary or not necessary. They are there to do as told. This should be a zero tolerance policy.
This attitude is a great way to get your ass handed to you as a resident.
And not by nursing.
It's also a terrible idea. The bactrim overdose at UCSF is a great example: https://backchannel.com/how-technol...t-38-times-his-dosage-ded7b3688558#.s3o8l1v4e
Nurses have caught errors I've made, big and small. Simply not doing something isn't acceptable -- they should contact me and double check. But sometimes something doesn't get done because another patient requires much of their time -- that's not ideal but sometimes for the best.
I think they should definitely question but if things are explained or you push and they still don't do it, that's unacceptable.
If you tried that attitude where I trained, the nursing staff would make sure to implement all your orders exactly as written. For example, when you write an admission order that you want to be informed whenever the HR was >100, they'll make sure to call you anytime the patient walks down the hall and gets to 101. What? You didn't want to know that? But that's what your order said.
Nurses are trained professionals that do have the ability to exercise some judgement, though that can be taken wrong. The appropriate way for them to go about it with an order that seems unusual or that isn't understood is to simply ask to clarify. Sometimes though, things get dropped because of the other 3 patients who also had orders written at the same time.
I always told my interns on their first month that part of your job as a physician is to follow up on the important orders and make sure they're implemented. **** happens.
I agree with Raryn's approach. However, you left too much out for any of us to be able to comment.
What was the order for? What was the patient's diagnosis / condition? How ,any other patients did the nurse have and what were their conditions?
In my experience, this is most likely a simple oversight or the nurse was just busy and hasn't gotten to it. Much less likely to be a flat out refusal.
What was the order for? What was the patient's diagnosis / condition? How ,any other patients did the nurse have and what were their conditions?
In my experience, this is most likely a simple oversight or the nurse was just busy and hasn't gotten to it. Much less likely to be a flat out refusal.
It's not an order. It's a "communication."
What?
SBAR-mediated preliminary medication administration action plan
Well it absolutely is an order, I do click on the orders tab to place it. A communication sounds like a suggestion.
You are actually ordering the start of a series of steps to safely give a medication, you 'should be' setting off a process with:
1. EMR alerts you to possible duplicate orders, allergies, and interactions
2. Human (pharmacist) verifies appropriate dosing, allergies, concerning interactions.
3. Nurse alerts provider if medication seems incorrect, inappropriate, or on the wrong patient
4. Nursing confirms medication name, dosing, route, and patient
5. Medication administered
Any one of these steps should go back to provider for clarification, and if safe/satisfactory answer is not provided then they should be able to go up the food chain (your attending, charge nurse, etc. etc.).
It would be completely inappropriate for any of these people in the line of these steps to 'ignore an order.' Seeking clarification for a satisfactory explanation is a requirement, not an option for the pharmacist/nurse/etc.
If they flat out ignored it and had no interest in seeking timely clarification, I would carefully document the situation through our internal patient safety reporting system. And that system would determine the response, all the way up to in severe cases being analyzed as a sentinel event, etc.
Don't train in NYC, kids.
