In reviewing files as a Legal Nurse Consultant one has to be acutely aware of the nurses’ responsibility in different scenarios.  Yes, physicians are held liable for writing inappropriate orders, inaccurate orders, and for not writing orders; but nurses, using sometimes simple knowledge and at other times specialized knowledge should know when to not follow these orders, to suggest a change in the order, or to suggest an order be written.  In this blog post I am going to give examples of when a nurse should not follow orders at all, suggest a change in orders, or to suggest that an order be written.  During my 30+ years at the bedside in the ICU’s at my hospital I learned that obviously all doctors are different.  Some are very open to suggestions and discussion; others are not so open and with these physicians one needs to take a little more time in their discussion about a patient so that when they are done the physician thinks that he thought about the change in order or the addition of orders.  All I cared about was that my patient get the treatment that he/she needed.  I would love some discussion on this post regarding the examples that I am going to give.  Do you agree that a nurse’s role encompasses this type of role?

There are blatant examples of “wrong” orders such as a physician orders Demerol 150 mg IVP for pain.  Or is this so blatant?  The literature states that the usual dose for Demerol is  50-150 mg.  The physician explains his reason for ordering this much as follows:  the patient has a high tolerance to pain medication.  The nurse gives the medication and the patient is found 30 minutes later in respiratory arrest status.  Is anyone at fault here?  I would say that both the physician and the nurse have liability here.  The order should not have been written, nor should it have been followed.  The nurse should have contacted the physician to let him know that she could not give this dosage of Demerol and her reasons why.

Here is an example that I was involved in back in the mid 1980’s.  I was working in the SICU and a friend of mine was working in the CICU (Cardiac Intensive Care Unit).  At that time the same nurses covered both areas.  Janet called me and ask me to come over and help her with the physician (resident that was on-call).  When I went over Janet was caring for a operative day coronary artery bypass surgery patient.  This patient’s systolic blood pressure was in the 70’s and the resident was insisting that Janet hang Nipride.  He said that the Nipride would decrease the patient’s afterload and his blood pressure would come up.  I told him that we could hang nipride, after we hung dopamine to get the patient’s blood pressure up.  He refused to do so.  I had Janet call the attending while I continued to discuss the issue with the resident.  He kept insisting that the Nipride be hung without the Dopamine; and he could not believe that we were not following his orders.  He said in his country the nurses did what they were told to do.  After the attending called back Janet hung the Dopamine and after the patient’s blood pressure was up she did hang the Nipride.   What would you have done here?

You are taking care of a post-operative coronary artery bypass patient that has an A-line and Swan-ganz catheter.  His heart rate is 124, his BP is 75/45, his wedge is 3, and cardiac index is 1.8.  The physician tells you to hang Dobutamine to increase the patient’s cardiac index.  I was in this situation and through a discussion with the physician I was able to get him to change his mind and hang Dopamine (Dopamine was his choice; I just wanted another drug besides Dobutamine and was hoping he would not turn to Levophed).  Yes the patient’s heart rate was elevated but Dobutamine is not recommended until you adequately volume resuscitate a patient.  If the nurse had hung Dobutamine and the patient’s blood pressure had continued to drop and nothing was done except increasing the dose of the dobutamine; and then the patient arrested would there have been liability?

You are reviewing a file where an elderly woman (85 years of age) has a surgery under conscious sedation; there are complications and she has to be intubated to protect her airway.  She has a history of an allergy to Ativan which causes her to become agitated.  The doctor orders Versed for sedation.  Do you give the Versed; because when you bring to the physicians attention that she is allergic to Ativan he says it is all right to give the Versed?  The patient subsequently has increased agitation which causes the doses of Versed to increase in amount and frequency; and then the patient has long periods of hypotension.  The patient wind up with decreased cognition and requires transfer to a nursing home.  She had lived independently prior to the surgery.  Was there liability in giving the Versed?  When I reviewed a case with this scenario I addressed liability with the giving of Versed and the ordering of Versed.  My literature included articles supporting the notion that Versed should not be given if you are allergic to any benzodiazepines.  It also included articles speaking to sedation in the elderly population.

The last example involves a post-operative coronary artery bypass surgery patient.  The patient’s post-op supplement orders include labs being drawn 6 hours post-surgery, morning of post-op days one and three.  Labs were also to be drawn one hour after supplements being given.  The patient is also receiving Bumex IVP every 12 hours.  The patient’s rhythm strips for the first 24 hours show no indication of ectopy.  Then on the evening of the first post-op day the patient starts to diurise and his rhythm strips show occasional PVC’s and PAC’s.  There are no labs ordered the morning of the second post-op day.  The morning of the third post-op day the patient goes into rapid atrial fibrillation and his potassium is 3.1.  What are your feelings about no labs being drawn the morning of the 2^nd post-op day?  I believe the nurse had a responsibility to ask the physician for an order to draw electrolytes due to the increased urine output and increase in ectopy.

 

Hopefully these scenarios will have caught your interest and we will have some discussion on this post.

 

If you have a case involving nursing negligence, Alvin & Associates, Legal Nurse Consultants would be happy to assist you with a review of your case.