Do you need to refuse an ED physician's order?
You aren't ready to rule out a cardiac cause to your patient's chest pain, but the ED physician orders a pain medication instead of nitroglycerin. When you question this, the physician insists the pain is musculoskeletal.
It's a harrowing moment for even an experienced ED nurse. What should you do immediately in this situation?
According to your state's nurse practice act, you have a legal and ethical obligation to challenge unsafe practices and orders. On the other hand, refusing an order without sound justification "will go nowhere," says Teri J. Cox, RN, MS, CLNC, president and owner of Point Pleasant, NJ-based TCK Consulting, a legal nurse consulting firm. "And for goodness sake, don't be confrontational and argumentative in front of the patient," she says. "Take it outside." Cox is former director of emergency services at Bellevue Hospital/New York University Medical Center in New York City.
Can you be fired for refusing to carry out a physician's order? Cox says this situation is doubtful, but you're at greater risk if you don't document, fail to follow the chain of command, and go against the hospital's policy and procedure.
Mariann Cosby, RN, MPA, MS, CEN, LNCC, principal of Sacramento, CA-based MFC Consulting, a legal nurse consulting company, says, "Remember that you have an obligation to advocate for patients. You have a legal right to not administer drugs you think will harm a patient." Cosby also is a practicing emergency nurse.
You might choose to exercise this right if you think the dosage is too high, if the drug is contraindicated because of a dangerous interaction with other drugs, or the patient's condition contraindicates usage. "Using critical thinking and sound judgment should keep repercussions at bay," she says.
In fact, if you perform an order that you believe to be incorrect, you could be named in a malpractice lawsuit, warns Elisabeth Ridgely, RN, LNCC, a Telford, PA-based legal nurse consultant and an emergency nurse at St. Luke's Hospital in Quakertown, PA. "The nurse can and will be held liable for administration of medications that are known to be incorrect, wrong dosages or wrong medications, despite the fact that she may have an order to do so. Complacency is not a valid legal argument," she says.
Refusal to administer a drug can have legal implications if the drug is ordered by a physician, however. Ridgely says the safest course of action is to document all conversations regarding the refusal. "If you are correct and move up the chain of command, then I see no legal ramifications for the nurse, if appropriate treatment is then provided," she says.
If you refuse an order, "document very carefully, with no personal feelings or attitudes. Chart the facts," says Cox. "If there is no record of unsafe practices, there will be no consequences to the behavior. A pattern of unsafe practice is key, not an individual occurrence."
Next, write an incident report, and notify risk management of any physician order or procedure you thought was unsafe and possibly harmful to the patient, Cox says.
Ridgely says to document all pertinent information: presenting symptoms, EKG results, laboratory results, and the patient's response to interventions. Also document your concerns and the fact that these were reported to the ED physician.
When you document in the patient record why the medication was not given, Cosby says to "include additional actions that may have been taken in this situation, such as notifying your supervisor and their follow-up actions, and your communications with the ordering physician."
Sources
For more information on refusing a physician's order, contact:
- Mariann Cosby, MPA, MS, RN, CEN, LNCC, Principal, MFC Consulting, Sacramento, CA. E-mail: [email protected].
- Teri J. Cox, RN, MS, CLNC, TCK Consulting, Point Pleasant, NJ. E-mail: [email protected].
- Elisabeth Ridgely, RN, LNCC, Ridgely Associates, Telford, PA. Phone: (610) 496-8610. E-mail: [email protected].
When in doubt, contact pharmacy Do you suspect an ED physician ordered the wrong dosage of a drug? Have you already checked with the physician who insists the dosage is correct? If so, call the hospital pharmacist, suggests Mariann Cosby, RN, MPA, MS, CEN, LNCC, principal of Sacramento, CA-based MFC Consulting, a legal nurse consulting company. "The pharmacist can either validate that the medication order is a safe dosage or corroborate the nurse's concern," she says. "Assuming the concern is confirmed, the nurse should convey the information obtained from the pharmacy back to the ordering physician, to ensure that he or she is aware of the data that supports the nurse's concern." |
You need to follow chain of command When Elisabeth Ridgely, RN, LNCC, a Telford, PA-based emergency nurse and legal nurse consultant, was caring for a patient during a code, a resident ordered diltiazem to treat an increased heart rate during a code. However, "the patient barely had a blood pressure and required dobutamine, fluids, or blood — definitely not [diltiazem]," she recalls. She explained her thoughts to the resident, who quickly acquiesced. Had the diltiazem been given, the patient would have become more hypotensive and probably not survived. "Had the resident not been reasonable, the situation could have deteriorated. I would have had to move up the chain of command," says Ridgely. Teri J. Cox, RN, MS, CLNC, president and owner of Point Pleasant, NJ-based TCK Consulting, a legal nurse consulting firm, says to follow these steps if you're uncomfortable with an order: Go to your charge nurse, then the ED attending physician if it is a resident order, then the in-house attending if you have one, then the ED nursing supervisor, then the ED nursing director, and finally, the ED medical director. "Rarely have I seen a refusal of an order go all the way up the chain, but I have seen it," says Cox. "It can generally be resolved at the charge nurse level." If everyone on the chain of command agrees with the physician's order but you still do not, here are some options: Ask for your assignment to be changed, have another nurse perform the order, or have the physician give the drug himself. "Of course, if the nurse allows the physician to administer a drug which she knows is wrong, then she has an obligation to report that to her superiors and the medical director," says Ridgely. If the ED nurse and physician are in conflict with each other, it could be one is less informed about a change in treatment practice, says Mariann Cosby, MPA, MS, RN, CEN, LNCC, principal of Sacramento, CA-based MFC Consulting, a legal nurse consulting company. When an admitting physician ordered medications and treatments for an asthma patient that were no longer the standard of care, Cosby notified the ED physician. He recommended that she go up the medical chain of command since he had no authority to override an admitting physician's orders. "After letting nursing administration know what I was doing, I spoke with the physician who was chief of staff and conveyed my concerns," she recalls. "Orders were revised based on his interventions." Cosby says "it all boils down to communicating your concern about what you perceive to be an inappropriate or potentially harmful treatment or medication with those who will support your actions to remedy the situation, and then documenting what transpired." |
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