A 9-month-old baby died in a D.C. hospital.
http://www.washingtonpost.com/wp-dyn/articles/A38515-2001Apr19.html
So this is my question: is working in a hospital like being in the Army, where you only follow orders? Is the doctor still God? Or is this just a single nurse’s screwup, a “shit happens” kind of thing?
No, believe me, docs are no longer God. It’s more of a tragic, terrible “shit happens” kind of event, where people just operate on autopilot instead of thinking. I’ve seen excellent docs and nurses do this, often about 14 or 15 hours into a long day, but it happens to the best of people when they’re fresh too, just not as often.
I chaired a committee responsible for the oversight of events like these, we reviewed thousands of cases over 5 years. When an event like that happened, we’d look for trends involving the individuals in the case, examining hundreds of their other cases. It was a tedious job, and generally we found these were isolated incidents by good professionals. And occasionally we’d find patterns of poor care that required action. We’d remand some people to further education, monitoring, restricting their work scope, and a few even got terminated, and reported to their respective licensing boards for action. But in most cases, I’d just shake my head over how such good people could make these mistakes, and be thankful that my mistakes haven’t turned tragic yet
Qadgop, MD
What’s a transcriber and what level of education does a transcriber need?
Jois
The transcriber (or ward clerk, as we call them) takes the orders written by the physicians and puts them “into the system”. I’m not sure of their education. However, if the doc actually wrote 5 mg instead of 0.5 mg, I’d say the clerk is not at fault in the least. It isn’t her job to know how much morphine is too much, although I wouldn’t be surprised if one caught an error like that. (They see a lot of orders.)
The nurses at my institution have no problem at all calling up the doctor to clarify orders, and I’m thankful for it. I would expect most any nurse (especially on a peds floor) to catch an error like that one.
Most hospitals are going to a more modern system in which the physician enters the orders directly via computer. The programs are set up to catch errors like that, popping up a window that says, “Gee, Doc, that’s a lot of morphine–you wanna check the Harriet Lane again?”
Dr. J
To the OP:
Excuse me - and I know you didn’t think of it this way - but that was pretty unnecessary for you to insult the Army the way you did. Soldier’s are not machines; they’re trained to think, and if necessary to challenge stupid instructions. After all, a soldier’s job is not to follow orders - it’s to successfully complete his or her mission.
Dorctor J said: “The nurses at my institution have no problem at all calling up the doctor to clarify orders, and I’m thankful for it. I would expect most any nurse (especially on a peds floor) to catch an error like that one.”
I wondered if the child was on a med-surg floor instead of a pediatric floor and if that threw the nurse off. However the whole hospital is a pediatric hospital so that shouldn’t have mattered a bit.
I thought I could remember a med nurse having to check the “ward clerk’s” copying of orders and then sign off, too. That error went through an awful lot of hands, but I’m still surprised the administering nurse didn’t catch it.
Jois
Nurse Practice Acts vary from state to state, but in my state (Texas) the nurse would be held liable. She would probably lose her license, and she would probably lose any lawsuit against her. Even if the doctor clearly writes the wrong dosage (say, if this doctor clearly wrote 5mg) the nurse would still be responsible for giving the wrong dose, even though it was ordered.
Nurses are expected to know the correct dosages of every med they give, any side effects or adverse affects that may occur, how that drug will interact with the others the patient is taken, and so on. I don’t understand how any nurse could give a total of ten mg’s of morphine to a kid without thinking something was screwy. Sheesh; that’s enough to kill some adults. If a doctor orders the wrong thing and refuses to change his order, the nurse must still refuse to give it: even if she loses her job, at least she won’t risk harming the patient or losing her license.
The unit clerk may be fired for an error like that one, but she has relatively little to lose. Unit clerks aren’t licensed, and they’re not held to codes of accountability as licensed people are.
Mistakes do happen. People work long shifts; they are tired. Nurses are overworked and don’t always have time to think things through. None of this makes tragedies any easier to bear. Unfortunately for nurses, the person who gives the med is the one who is responsible if anything goes wrong- and nurses give the meds. If the doc writes an order for the wrong dose or the wrong med, it’s the nurse’s duty to call him on it.
Also, the nurse should have read the doctor’s original order, not the unit clerk’s transcription. (What’s a unit clerk doing transcribing med orders, anyways?)
Why are doctors and nurses, people on whose skills our lives depend, working 15 hour days? Especially if we know, as you assert, that even good professionals are prone to making mistakes when they are overtired and overworked?
I saw a news program do a story about this issue once. A doctor in charge of a medical school claimed it was necessary for residents to work godawful long shifts of up to 48 hours in order to pick up the skills they needed. Sounded like a crock to me at the time - more like a way to keep from changing his system.
Airline pilots have a mandated amount of rest they must get in between flights. Why not doctors and nurses? You’d think they’d need it more than anyone.
I agre with you Grok; seems as if these administrators don’t seem to know or care that sleep deprivation affects performance of docs too.
In my line of work, I notice mistakes all of the time in forms. I inform my supervisor of those mistakes, and sometimes correct them on my own. An order of 5mg of morphine should have raised warning bells in the administering nurse’s mind, and that nurse should have questioned it.
A crock then, and a crock now. The reason residents work that many hours is a combination of necessity (someone has to be there) and machismo. A lot of places are going to a night float system, in which one team of residents comes in and covers the night shift, which mostly does away with the 36-hour shifts. Programs that do that will certainly be bumped up on my match list next year. 
Dr. J
We do need it, we don’t get it. Somebody’s got to be there 24/7 to take care of sick people, and there aren’t enough doctors or money to pay them to cover 3 shifts with 3 sets of personnel. Administrators look at the bottom line only, they mandate more work from the same number of people to provide coverage. The longest shift I put in back in residency was 56 hours, the longest in private practice was 36 hours. It sux, but somebody’s got to be available. And patients are demanding more and more “convenient care”, that is medical care and testing that won’t conflict with their work or family hours, and the damned administrators are giving into them, so we do stress tests in the evening, or on Saturdays, so people won’t miss their big projects at work!
I think the reason why doctors work hellish shifts is different than the reason why nurses work hellish shifts.
Medical schools traditionally require docs-in-training to work insanely long shifts to “toughen them up”. It ensures that only people who really want to be doctors get through. (It also tends to dissuade undesirable people- women who have or want kids, for example- from becoming doctors. IMHO, YMMV.)
Doctors are generally not employees of the hospital: they are free agents, and hospitals cater to them shamelessly because doctors bring patients; patients bring money. At my hospital, there is an official policy that whenever a doctor screams at a nurse, other nurses may stand silently behind the nurse who is being berated to show support, but no nurse may “talk back” to a doctor or she will be fired. We’ve had doctors who throw bloody body parts and surgical instruments around in the OR during fits of rage; those doctors receive no warnings even though throwing a bloody scalpel is clearly a threat to the lives of the nurses present.
Nurses are hospital employees. Hospitals emphasize that nurses are their single largest cost. (Well, duh- you can’t have a hospital without nurses, and the majority of care received in hospitals is nursing care.) Hospitals are always trying to cut back on the cost of nursing.
Having nurses work long shifts is one way. In some hospitals, nurses work 8-hour shifts. Around here, nurses work 12. (Once you give report to the oncoming shift, do your paperwork, and catch up on the work you didn’t have time to do during your shift, this equals about 14 hours or more.) Having only two shifts per 24-hour period saves the hospital scads of money.
Another way hospitals save money is by increasing each nurse’s patient load. When I worked in ICU, my hospital decided to give each nurse 3 critically ill patients instead of the usual 2, promising to provide plenty of (unlicensed) aides to help take up the slack. They also eliminated all of the phlebotomists, most of the x-ray techs, all of the EKG techs, most of the central supply staff, and others, reasoning “Now that the ICU nurses have all of these aides to help them, they’ll have plenty of time to do those jobs, as well”. Needless to say, those promised nurses’ aids never materialized.
Human error occurs. I just read my RN Update, which lists every nurse in the state who has been reprimanded by the state board; two close friends of mine have had their licenses suspended. Nurses (and doctors too, I’m sure) live in fear of making a mistake. We try so very hard not to make mistakes, but sometimes the system or our own weariness or our own carelessness defeats us. It’s a scary job.
As a student RN, I know that 5 mg of MS is too much for a baby. After checking the MD order,looking up the dosage in the med book, calling the pharmacist, talking to the MD on the phone, if the order stood, I would have to inform my charge nurse that I refuse to administer that med. I’ve worked a lot more Med/Surg than Peds, so I would be super-cautious if I had to float over there for the shift. My charge nurse then decides what to do—that’s why s/he’s in charge. The I document everything. And if that child needed that med for reasons I can’t know, (but what? Excruciating cancer pain?)the patient gets the med. But I would not administer it and I would’ve intervened on the patient’s behalf, because I KNOW that order isn’t right. If I go through the correct protocol and document, I can’t be subject to discpline and my patient gets the care needed.
Every one makes mistakes and it’s up to the team of MD, pharmacy,unit secretary transcriber and RN to back each other up and deliver safe patient care.
Hi Holly. I hold nurses in high esteem. They have taught me much about medicine and patient care. I don’t know where you work, but around here, the docs no longer get away with the kind of behavior you describe. We just mandated that one doc be evaluated as an inpatient for anger management problems for throwing things. Around here (Southeastern Wisconsin) it is becoming zero tolerance for verbal abuse too. One surgeon was instructed by the department chair to apologize for raising his voice and swearing, or risk losing privileges. Hope that spills over to where you are. That kind of behavior is appalling and has no place in medicine.
Hospitals don’t cater to us around here anymore either. With managed care, and provider-employer contracts, the docs generally have little say as to who their patients are and where to admit them. I’m locked in a system where they tell me where to put them! And who to consult, and what meds to use! Sure, you can go outside of it, but it’s a lot of red tape and arguing to accomplish it.
The ancient days are over, the elder days have passed, and I’m already a nostalgic old fart at 43. Alas! Alas!
Way to go, Cyn. Documentation is the key.
Yes, but if your charge nurse asks you to do something that you suspect is wrong, don’t take her word for it. I was lucky in that every charge nurse I had was extremely knowledgeable, patient with my hundreds of questions, and supportive. Still, charge nurses are people, too, and they can make mistakes, too. If your charge nurse tells you to do something that you are uncomfortable doing, she should do it herself.
You don’t have to be a pediatric nurse to know 5mg of morphine is way, way too much for a baby, since it’s a hefty dose for an adult. Question everything. Doctors will scream at you, administrators will scream at you, but follow your practice act to the letter.
Quadgop, nice to meetcha.
The problem here is largely because we have plenty of nurses- most of them are green, fresh out of school, but there are plenty of warm bodies who will work for next to nothing (at least for a while, before they get fed up and go back to waiting tables).
Doctors who show respect to nurses (and I mean merely treating nurses like human beings) will receive better care for their patients. When a nurse is afraid to call the doctor because she knows he will shriek at her, the patient is more likely to suffer. When doctors communicate with nurses without screaming (they are few and far between here, alas) the nurse can tell the doc pertinent information and they can work together to enhance the patient’s care. Teamwork is what it’s all about.
Yes, nurses are “inferior” in that we have put in fewer years of college. I’m sure doctors get frustrated because some nurses really are incompetent- but it’s The System that favors the employment of incompetent nurses. I made more money waiting tables than I make nursing. We’re a disposable commodity. Yet, a good nurse can make all the difference in a patient’s life- it’s sad that the “bottom line” comes before good patient care. :sigh:
There is another interesting thing happened here: Georgetown Univ. Hospital IIRC was facing nursing shortage and recruited 200 nurses from ? Columbia, someplace not here. Someplace not primarily English speaking and not US educated. I can’t begin to imagine supervising that mess.
Jois
In the US, nurses have to be licensed to practice in the state where they work. Each state has its own licensing board. Those nurses must have been qualified and fluent enough to get licensure from the state; the hospital can’t and won’t hire them otherwise.
Are you sure there aren’t temporary exceptions? For example between the time a nurse graduates and takes the RN exam? There might be others as well. States grant reciprocity to nurses from other states, there might be stipulations for nurses from other countries, too.
Jois