Survey re: med clarifications

[LegalEagleRN]

I am reviewing a defense case for an RN and am trying to get a good idea of how most nurses would handle this situation. I am NOT wanting to find out how it should technically be done if by the letter of the law. So please, answer honestly about how you personally would deal with this situation.

I have divided this into several sections, please read one section and answer the question BEFORE you read the next section.

You are the night shift nurse on a telemetry unit at a mid-size hospital (300 beds). You receive a call from the ER nurse about 2045 to give you report for a patient you are admitting. Report is as follows:

Patient is a 42 year old overweight diabetic female who came to the ER about 4 hours ago complaining of drowsiness and lethargy for several weeks, much worse today. Her blood sugar on arrival to the ER was 419. She is sinus rhythm on the monitor with an unremarkable EKG. Lungs are clear to auscultation and there is no edema in her extremities. Her potassium is slightly low at 3.2, otherwise labs are normal range. The patient was diagnosed with diabetes 3 months ago and has been checking her blood glucose twice daily since then and has been averaging 500-600 most days. She is prescribed Metformin but it doesn't seem to be having any effect.
An insulin drip using the glucommander (program to optimize insulin gtt) was started 3 hrs ago, and the patients blood sugar has come down to 206. The on-call physician has seen the patient and wrote orders to give 70 units of Lantus and then discontinue the insulin drip 2 hours later. There are also orders to start a drip of NS with 20KCl at 100cc/hr for 12 hours, then d/c. Patient is currently drowsy, but alert and oriented x3. Patient will be brought up in about 15 minutes.

Question 1: Do you have any questions or concerns at this time regarding what you have heard?? :23:



***STOP...DO NOT READ FURTHER UNTIL YOU ANSWER THE ABOVE QUESTION




OK... the patient arrives on the floor about 2100, is able to ambulate without difficulty from the ER cart to the bed. You take the orders to the desk and fax them to pharmacy, then return to complete the Admission Database. Patient has no significant history except the recent diagnosis of Diabetes. She confirms that she has checked her sugar twice daily and averaged 500-600 for the last few months. You ask if she is on insulin at home and she says she just takes Metformin, 1000mg BID. Your physical assessment reveals no abnormalities or other issues. You orient the patient to the room and unit procedures, then leave to review orders and put the chart together (no unit clerk at night). You review the chart, put orders in the computer, verify that the orders were received by pharmacy, look at labs, then the glucommander alarms telling you its time to check the blood sugar. Her blood sugar is still not in the goal range of 80-150 so you increase the insulin dose again based on the computer model. Patient is hungry so you get her a turkey sandwich from the unit kitchen and a pitcher of water. At 2300, the medications arrive from pharmacy so you start the NS with KCl in a new IV (not in the AC which would alarm all night) and give the prescribed 70 units of lantus. Shortly afterwards, you check her sugar again and it has gone back up over 200.

Question 2: Is there anything you would have done differently at this point had this been your patient?? :23:




***STOP...DO NOT READ FURTHER UNTIL YOU ANSWER THE ABOVE QUESTION





At 0100 you discontinue the insulin gtt as ordered, her blood sugar is still greater than 200. Patient was sleeping soundly when you entered the room, but awakened easily. You tell the patient you will be back to recheck her blood sugar in a few hours to make sure there isn't a need to restart the insulin drip.


Question 3: Do you have any issues or concerns at this point?? :23:




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At about 0315, you are reviewing the MAR's for the next day on all of you patients. You find that the pharmacy has entered the Lantus dose incorrectly for your new patient and put 7 units instead of 70. The pharmacist asks you to send a clarification then he will change it in the computer. You quickly verify the written order and remember what the ER nurse had said, then write a verbal order from the admitting Dr. (not the on-call doctor) and fax it to the pharmacy. You recheck about 30 minutes later and the dose has been corrected to 70 units Lantus q HS on the MAR. You also check a blood sugar on the patient at this time and it is 203. Patient is normal. You check the sugar again at 0500 and it is 198, patient is normal.



Question 3: What would you do differently (if anything) in the above situation? :23:





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At 0615, you awaken the patient for her morning meds which she takes without difficulty. Patient is normal. At 0630, the on-call physician is making rounds and sees the med clarification and tells you that the order was supposed to read 7 units Lantus, not 70 units. You show the Dr. the written order that says 70 units and the Dr. says the '0' is actually the 'u' in the word units. You tell the doctor that the patient received 70 units of Lantus at 2300 and is doing fine, in fact her blood sugars are still right around 200. The Dr. writes an order to d/c lantus and to continue accucheks every 2 hours for the next 12 hours. The Dr. says that you should have called if you had any question about the order and should not have written the clarification without speaking to the physician. You tell the Dr. that you had no question about the order as it was verified by the ER nurse in report, and it seemed an appropriate dose considering the patients history and status. You report off to the incoming RN and advise them what happened and to check the blood sugars q2 as ordered. Patients blood sugar at 0700 is 201.


Question 4: What would you do differently (if anything) in the above situation?





***STOP...DO NOT READ FURTHER UNTIL YOU ANSWER THE ABOVE QUESTION



You return to work that night and find that the patient was discharged at noon that day, no adverse effects were noted and patient was prescribed Lantus 30units qHS with followup in one week with her physician.


Question 5: Do you do anything at this point??






Thank you for your responses to this survey...

[AmandaWIRN]

Ok, I'm not going to write up answers to the whole darn case, but to me, if anyone is to be blamed for anything here, it's the physician who wrote the order. "u" is not an acceptable abbreviation for units for this very reason. If the ER nurse and floor nurse both read the order as "70," instead of "7u" then it obviously looked enough like 70 for both nurses to read it that way.

Yes, the floor nurse should have called the physician to clarify, but ultimately, the error began with the physician using an unacceptable abbreviation.

There were no adverse affects on the patient, so why has this become a lawsuit??? What damages are there to sue for if the patient was discharged home the next day with no untoward results from the higher dose of Lantus?

Actually, the higher dose probably did the patient more good than the smaller dose would have, considering her sugar continued to remain high several hours later....

[SkiMedicKC]

Long post, but here goes:

1. I don't see anything wrong at this point, makes sense to me.
2. Sounds good, I assume from the post pt. has no other major medical issues to deal with at this time.
3. What's to be concerned about? Nothing is going on from what I read. Since the nurse had no question about what the order read and was just trying to get the pharmacy to correct it, this happens all the time and docs don't want to be bothered with this stuff.
4. The nurse did everything right from what I read, told the Doctor what was going on and nothing else needed to be done. The info was passed to the next shift appropriately. Besides, 7 units of lantus for a patient like this coming off an insulin drip is just a stupid order.
5. Obviously, the Dr. was wrong, nurse was right in this situation; sounds like the Dr. is trying to CYA and somehow blame the nurse for something (not sure what, though). If 70 units had been an inappropriate order, the nurse should not have given the dose, but it was obviously appropriate since the patient went home a few hours later.

We all write orders like this when doing MAR checks. If I have no reason to question the order and am just getting the pharmacy to correct the MAR I never call the physician, they don't want to be bothered at 3am for this kind of stuff. Typically, they will see the order the next day and initial it. If the pharmacist was concerned that the order was incorrect, he/she had a duty to contact the physician directly for further clarification.

What happened to the nurse?

[LegalEagleRN]

Thanks for the prompt replies so far. As far as the RN, here is what has happened so far:

The nurse has been an RN for almost 13 years working primarily ICU and ER with some Tele. She has been a traveler for about 5 years and never had any complaints. About 5 days after this incident occurred (on a Tele unit), the nurse was called and told not to report back to work that night as her contract had been canceled. (This was just one week before she was to receive a $3000 bonus). She was told that the hospital decided she was trying to cover up a mistake by falsifying a physician order. She had no advance notice that there was any concern about this situation and did not get any opportunity to defend herself to the Quality Review Board. In addition, the hospital decided to report the situation to the Board of Nursing for that state. Incidentally, the nurse was on her second contract renewal for that facility so they were obviously pleased with her work to that point.

I am working with the attorney on a wrongful termination lawsuit attempting to get the hospital to pay her the remainder of her contract, rescind the notice to the Board of Nursing and also obtain damages from the hospital.

Hope this answers your questions about the RN.

[AmandaWIRN]

Terrible. Sounds like they didn't want to pay her the bonus she was going to be getting. Unfortunately, I have heard of several people who have had this done to them. That is why I won't take an assignment with a completion bonus. If they want to give me a bonus, they can add it on to my hourly rate....

[stellar]

OK, I am going to be the hard nose: I absolutely would have called for clarification of that order. Just because a doctor wrote it illegibly or with an unacceptable abbreviation, it is the nurses responsibility to make sure it is correctly interpreted, prudent, safe practice, etc. I also do not write orders I never received. I have watched doctors deny verbal orders they actually gave, never mind ones they did not give. Doing that, in MHO, is diagnosing and prescribing, which in Florida nursing practice law is outside of the scope of practice. It is a nightmare having to call an MD in the middle of the night particularly for clarification of an order, and social pressures often tempt us to forego it, but here is a perfect example of why you have to bite the bullet and call both for the sake of the patient and your license, (and in my case it would be done unapologetically, this, after all, is their job and patient as well.)I also would have asked if an ABG was done and what the PH was. A serum K of 3.2 in DKA will drop precipitiously once the acidodis is corrected, as well as the insulin drip which will also cause the K to go back in to the cell causing a more severe serum hypokalemia, and the pt can die of arrhythmias in short order. I would have expected repeat serum labs also, not just accuchecks. On a nurse advocacy note though, this sounds nightmarish. Something one traveler said to me impressed me enormously: she said, she practices like no one is watching her back, and this case shows no one was for this unfortunate nurse.

[LivingDeadNurse]

okay i would have gotten a clarification after the RX had flagged it. they are like our back up. i have had that happen a few to many times. dr. writes order which is dosed wrong because he is in a hurry and they catch it. any time rx can' t read it always get a clarification from the doctor that wrote it. But the doctor shouldn't have wrote U for units i has been banned for awhile in most facilities. so he is not clear from blame either. but i don't know any nurse that can say that they haven't made some type of med error. it happens...we are human. the facitity over reacted and didn't want to pay her bonus.:33: