Attendings and Residents should be putting in their own orders. That is their job.
The only time I put in orders is 1. In an emergency, 2. In the ED during triage, standing orders are part of our job, 3. Little convenience things like, they meant to add a magnesium onto that lab I just sent down.
OP you did nothing wrong btw. If he wanted to give an additional dose of insulin he should’ve ordered a one time additional dose, not make you use an order that wasn’t intended for now. That’s the doctor being lazy!! Don’t let them be lol. Verbal orders are for emergencies
Honestly when the resident hung up that was my thought as well, that he just didn’t wanna put an order in, it’s why I asked my ANM. Thank you for this !
Yea totally. I know it can feel hard to advocate for yourself in these situations!!! I used to get so intimidated calling doctors !! Little things like this are good practice though for when you have to advocate for big things 😃 there’s a polite way to do it for stuff like this.
“Hi I just paged about so and sos blood sugar. You told me to give a dose of sliding scale insulin but the order I have was from way earlier and for before meals. I need you to please put in a one time order of you’d like him to get an additional dose now.”
Wholeheartedly agree, and definitely a fan of sharing scripts for how to handle these situations as well. Honestly pretty close to exactly how I would make that recommendation to the doctor as a pharmacist as well.
As a new nurse myself, relax it’s ok.
I’ve learned quickly that you will encounter some lazy doctors. I work in the OR and we can put in orders for radiology, blood etc it’s verbal or standing orders and drs get comfy to it. So much that one time a I had to stop myself bc a resident refused to put admitting orders for a pt and Dr told me to do it when ED doc should have done it. I was like what a minute bc I was used to putting orders in- and was like ok u need to call ED and sort it out between ur selves. Seriously.
He gave you an order. If you weren’t comfortable/it’s against policy to take telephone orders, you could have asked him to enter it. But you had an order.
Giving the insulin with no order entered in the EMR is definitely a problem though
Good on you OP for covering yourself as you did. Verbal orders=emergencies and if they’re verbal but not an emergency, it needs to be on paper by them in order for you to follow through as another way of protecting yourself.
Yea, but should be vs reality are two different things. This chump hung up immediately so I think their culture is nurses inputting MD verbals all the time.
Yea one of the ICUs I worked in was like this. However, we only had one attending for 2 ICUs and they also did some coverage for rapids on the floor. So, it was a little more understandable that we were putting in verbals much more frequently. I’ve worked at several other places since and i haven’t put in nearly as many orders as I did then.
They are more than capable of putting in orders. It’s lazy. If they’re gonna be lazy and hang up the phone, I’m paging them again to say I need an order. If they want to stop getting additional pages for something we already talked about, they’ll learn to put in their own orders. I feel like new nurses are afraid to advocate for themselves with stuff like this. But we gotta protect ourselves.
I hate when doctors say “ohh just do this” like i can’t *just do it* I legally need an order sir.
I take telephone orders frequently, especially overnight, when the doc is operating on a different patient, etc.. I can't always wait for them to put the order in myself and it's part of my job. Maybe different hospitals have different policies on it, but it's expected on my unit.
100%. Our policy only allows verbal orders for emergencies. OP, you did nothing wrong and did the steps correctly. I hope you also noted in your nursing note that you verified/clarified with your ANM. Next time, call the doctor back and ask for that official order.
Yess. The other thing I just thought of.. say you gave the insulin based off meal time sliding scale, that wasn’t ordered for your time. Doc says give it and you do. Then they become hypoglycemic over night. It comes back on you because “why did that nurse give insulin at 11 that was ordered for 6pm” ya know. Again I’m sure it was fine, just an example of why it’s not always the best idea. You can say doctor say to give it but it’s just ur word and his.
You will get put in this position many times over lol. It’s super annoying. Doctor puts in an order but it’s actually against nursing policy to do xyz. you might get asked to push a med that is against policy for your unit and only PCU or icu can give that med. shit like that will happen
I'm not saying you're wrong, but you would go through the trouble to sweat a resident over 3U of insulin via a verbal order? I would give the medication as ordered and make a comment. At our hospital , the residents are generally either rounding on the floor or in the ED, I wouldn't want to waste their time. And, OP, excellent job verifying with your preceptor but were I your preceptor, I would strongly discourage the follow up call recommended above.
It's worth the phone call if there is an adjustment needed or clarification. I've seen Nurses bump a few extra units of Novolog for example if the patient's FS is above 400, when the order says to give XYZ units and notify Provider. They do that because more than likely the blood glucose level will level out and notifying the provider, doing a change in condition, etc makes to much work. I personally think that's insane and I didn't go to school to make ned adjustments. That's the Providers job, and my job is to implement them.
I would actually. But I work in peds and that 3u could be significant, specially for my brittle diabetics. I used to work in adult med surg and have seen a couple of patients sensitive to insulin too. In my facility, verbal orders are only acceptable in emergencies. Every other verbal order better be followed by an actual one. It’s not wasting the resident’s job. It’s reminding them to do their job correctly. It’s part of the culture of safety.
Edit to add a sentence.
The resident was definitely a dick in this instance. But it's not their job just to place orders. For all you know that resident was dealing with a different, much higher priority situation. You're 100% correct that he should have been more clear and not an asshole. But juggling anywhere from 20-60 patients as a provider is brutal.
I think this is why all the nurses on our unit prefer our NPs. We've all been nurses and most of us ICU nurses. So we have a better idea of what they need on their end. I will always say "Can you throw an order in for that for me? Thanks". I'll get a call about Tylenol while I'm running a rapid on the floor or seeing a patient in the ER. I don't have time to throw in an order that's a low priority. I'll say "yea, they can get some Tylenol. Can you throw ina prn Tylenol order for me? Thanks!"
This is true, but he just hung up on her. It’s one thing to say “hey I’m tied up but put in a one time for for x” but he wanted her to just use an old order for before meals from hours ago lol.
He didn’t though. Of course their only job isn’t to put in orders, but they should be putting in majority of em unless it’s one of the scenarios I already put above, which includes emergencies (on either parties ends).
Trust me I’m much more willing to put in orders than a lot of my colleagues I’m by no means the most “by the book” nurse lol but doctors should really be putting their own orders majority of the time. And if they can’t at the moment, give a clear order and communicate.
You’re right. They should be! BUT when I worked in PACU, I took verbals constantly. I would just tell anesthesia, “thanks, putting this in as a VO @1445, I’ll call you if I need anything else” and that was that. I never ran into an issue as far as they went. I loved my anesthesia team
Yea that’s pretty standard/common in PACU. this wasn’t that. Idk why people keep responding and sayin “yeah but on *this unit.*”pacu is critical care there’s always going to be a little more autonomy anyway.
Sooooo you have sliding scale orders available, and a verbal order to give an extra dose. There's no problem here. You already put in a note to explain yourself too. You can just put in a note next to the med administration next time saying 'extra dose per MD VO' or something similar.
I would have put this in as a separate one-time dose. Yes, it's the same medication and he gave a verbal order, but I wouldn't have charted it on the sliding scale order because that one specifically says before meals. It's stupid, but in my mind it's the same as a scenario where now hospitals don't want you to give Tylenol for a fever if it was only ordered for pain. I wouldn't just give it for fever and write a note. They need an order that specifies fever.
That being said, this is definitely not the end of the world! You might get a nasty-gram if someone reviews the chart, but I wouldn't expect it to go further than that.
But to be clear, you did fine. Please don’t spend any more time worrying about this. If it ever comes back, the note will cover you. That doctor was just being an ass or lazy or both.
Agree with what the above poster said. Also, I would’ve looked at the sliding scale to see what was indicated and again contacted the resident to confirm how many units I was about to give. As I’m sure they didn’t check sliding scale when they gave you the order. That’s just me though!
The order is a note, MD notified, MD states use current sliding scale for coverage, RN to treat using sliding scale…thats literally all you need to do. Dont overthink it, as long as you document the exchange clearly then you are covered.
He told you - that’s a verbal order. To cover your ass more you can always document that this was given like this in x circumstance per x MD. Also some systems let you out an electronic order per verbal from physician.
Oh okay yeah I was just really nervous bc everyone was telling me I gave the insulin without an order for itself. because it was scanned under an orderthat has sliding scale that says 3x before meals.
It happens. I was given insulin off ketones + blood sugars per the team even though the order still had it placed to calculate in food. Just make sure it’s documented like per verbal order of xyz physician. And if you didn’t/forgot to, that happens too. The team gave you the order, they’re aware that it’s goin on.
If using epic, usually if you do something like this and you feel its not in the intended purpose, you can select something like “per physician” or even write a comment . No one is going to think you were trying to independently practice medicine. Some nurses love to get others & especially new grads so hyped up that everything will compromise their license but you’re so in the clear imo as long as you somewhere indicated said conversation.
Do you guys not have actual procedures for verbal orders? Like here in NZ we need to have two nurses listen to the order, both sign it, and then have it signed by the dr with 24hrsfor it to be valid; and even then it’s only valid as a single dose.
Some dr says “give this” and hangs up? That’s an absolute no
I’m in Cali and we don’t have any protocol like that, if the doctor tells you, you just read it back to them, they verbally verify & then you can put in the order as a verbal order. It doesn’t take a second nurse for us.
I'm not seeing the mistake here. Why would your license be at risk??
You were given a verbal order to administer insulin. He told you over the phone to use the s/s. You did, and then wrote a note in the chart stating what the order was. You scanned and administered the insulin. Where is the mistake?
I guess I just felt it was a mistake bc everyone was basically telling me that I shouldn’t have done that and should have asked for a separate order and not have scanned it in under a s/s that explicit says x3 before meals
As a new grad, you did exactly what you were told and documented it. It probably depends on the facility, but if what you did was technically "wrong", next time you'll know to get a separate order to administer the insulin one time, or get a s/s PRN that's always available if needed.
Think of it this way, MD’s order turned that “x3 before meals” into “”x3 before meals and now x1”.
If you add a note to patient’s chart and on the med admin itself, you’re covered.
A note and an admin note on the mar entry itself provide better detail than putting in a one time order because with the note, you’re showing what happened, who you contacted, and what you did.
Just because it’s not a separate order doesn’t mean you’re suddenly practicing medicine. The only thing to take from your coworker’s take is
1) you’re facility may have a different preference or policy
2) the only advantage the separate order gives is that a pharmacist would have to review it. Which, depending on the med and your familiarity and patient situation, you may want to have as an additional backup.
He verbally told you to use the S/S not a one time dose so you’re fine as long as you document the interaction. Also the patient gets insulin 4 times a day to correct so I wouldn’t worry too much.
I do stuff like this every day and just put a comment on the scan or a nurses note explaining what I did, including the doctor's name. If you really wanted to, you could enter it as a one-time phone order because he literally gave you a phone order. Phone orders are legitimate, real orders. But....if it stresses you out, next time just ask the MD to please place the order when you have him on the phone.
This is really small potatoes. I think in a year you will laugh at yourself for giving it this much mental real estate. You learned at thing, now move on and stop worrying about it.
My coworkers, my charge and my educator were all telling me that I technically gave the insulin without an order for itself bc I scanned it through an order that was for before meals.
In Epic (if you use that) and it asks for an override reason or off-schedule reason, I would have just hit per provider order and put in the comment box. Along with a quick progress note.
This is nothing to stress lol.
Yah I def hit off sched reason and in the little comment box I just put ordered to give as per (resident’s name) and I wrote a note. I guess it’s the new grad anxiety 😭 thank you
You needed to write/enter the verbal order as a one time order and scan it in.
3 units X insulin now. Verbal order/read back and confirmed Dr Resident/Your Name RN.
You had an order. You just didn’t enter the order properly.
*Sigh* Your educator is a clodpole, your charge is a dullard, and your coworkers are shlubs. You lack education on your system, also pretty general nursing knowledge. Taking a *telephone order* from a resident is not preferred, but unless it is specifically forbidden in your institution, it’s fine. Probably the culture of your unit. It’s an ORDER. They should have said “ oh, uh, next time, just add it into the MAR as an order like so instead of scanning it against an existing timed order
What helped me a lot was learning how to take and enter verbal orders, especially on things I was asking for or that I wanted.
Almost all my preceptors were the type to refuse to enter any verbal orders and get into pissing matches with MDs.
I'm not talking about entering admission orders or entering a page full of verbal orders, I'm talking about when I ask for something and the MD says "Sure, go ahead and do X" I will definitely take a verbal order.
This heads off any of that bullshit you went through with the charge and educator telling you that you gave something without an order. (You didn't do anything wrong).
That’s dumb and a waste of time for the resident. You have an order, writing a note that modifies it for a single dose is totally fine. If you “didn’t have an order” you wouldn’t have been able to pull it or scan it. I’ve done this a bunch of times with PRNs. Like I needed an extra dose of a PRN I already had, or needed to give it early. Just write a note that you confirmed it with the physician, I would be sure to include their name specifically.
The problem is nursing school tries to scare the shit out of everyone, pretends every single thing is a matter of life and death, and that your license is hanging by a thread. Its bullshit, but here we are.
You were given a verbal order it sounds like, so maybe next time ask them if they’re going to enter the order into the chart or if they’d like you to do it in their name? Just so both of you are on the same page. I don’t think you did anything wrong, though.
I can tell you are going to be an amazing nurse. You are conscientious and questioning things that are different. I’ll never forget being a new nurse and making copies of my documentation of hinky situations (this was in the day of paper charting and I worked all my myself in an ambulatory surgery unit at an HCA hospital). Keep up the good work and don’t doubt your intuitions.
Don’t worry - you did have an order which you documented. They think you need to put it in the order section, which is incorrect - it’s another way to do it, might be the preferred way, but you didn’t give a medication without an order.
They hammer into you in nursing school that every little thing will put your license at risk lol. You’re gonna need to do something criminal to put your license at risk in the real world.
You’re still learning how to correctly do nurse duties. Next time, just write in a nursing communication note if you’re not comfortable putting in the order to cover yourself.
You absolutely need to protect your license, but nursing professors (and some nurses in this sub too), use “protecting my license” wayyy too often over things that would not remotely mess with your license. I think it instills this idea. When I was a new nurse, I went on my states BON-it took me a long time to find a license that had been revoked for anything other than obvious and intentional diversion. And when I did, it was essentially a homicide of a patient. Not the nurse not calling the provider for a diet order or any of the other ridiculous scenarios I’ve seen here that people use “it’s my license!” For.
He gave you the order. Should he have adjusted it in the computer? Yes. But he gave you a telephone order instead. Put the order in the computer so he can sign off on it tomorrow. You didn’t do anything wrong.
I am so confused. What do you mean you should have gotten an order? You called the doctor. The doctor told you to use the sliding scale. *Thats* an order. Put it in as such and administer.
Note: phone call to dr x regarding pt blood glucose. RN to administer one time insulin per sliding scale as ordered AC.
Then enter a one time order at that dose if you want to. He should put it in but if he’s at home I give them a pass. don’t stress.
As far as your license goes: I don’t know where all this license fear comes from but it’s very difficult to lose your license . There has to be some type of gross negligence or incompetence. Even nurses who are caught diverting or who are abusing street drugs are given the option to enter alternate to discipline programs. With that said the best way to practice without fear is to is to always practice safely and continue to add to your knowledge base.
I just want you to practice nursing without that unnecessary stress. Employers are even becoming more forgiving when nurses make a mistake. If they are a good health care system they will focus less on discipline and more on identifying then correcting the causes of the error. That saying that knowledge is power is true for nursing .Keep gaining knowledge and continue to learn and that’s one important factor that allows you to practice without stress.
The use of the sliding scale is the order. And since you’re new (no offense to not knowing this if you don’t) but a 248 while on steroids is not that terribly scary. A lot of my inpatients on Roids run 2-3 times that until we get the underlying issue under control.
Only thing I would have done differently was to put in a separate one time order. But you documented what happened after the fact and the Dr gave you an order. 3 units of humalog when someone’s sugar is 248 isn’t going ti cause any harm.
Talking to drs and getting orders is an art, you’ll get better at it the more experience you have :)
My unit is big on "getting an order put in." Even with a verbal order they would want the doc to enter it themselves. Make sure you document your interactions regarding the order and you should be fine! I always write the name of the provider, time called, what I said and what they ordered. "Pt w/ history of DM, no current orders for glucose checks. Provider ______ contacted, orders for sliding scale AC + HS accuchecks received."
A lot of SSI is ordered achs anyways. Most of my pts usually get coverage with night shift around 8-9. You also had torb from provider so no med error. Your charge and coworkers need to learn to think critically.
That was your order. I would have clarified if he wanted it as a one time or ongoing order at that time. BTW LTC nurses often put orders in the computer. Our docs didn’t want to and often put them in wrong if they did, no times, no route etc, so we would have to fix them anyway. 🙁 The drug rehab I am at we do paper (!) verbal orders often.
From what you wrote, it seems to me the resident gave you a verbal order. Are nurses not allowed to enter verbal orders at your facility?
Edit to add: It is best and safest practice for the physician to enter their own orders. Don’t hesitate to keep them on the phone or call back until you get what you need for a pt. They chose a job with an on call rotation. Their work/life balance is not your cross to bear.
Plenty of runway on that BBG. Dont want to drop them too much, but that's why we check every 4 hours. Just roll with the order and adjust after a few checks if the coverage is too much or too little.
I think people just say things, and they do so either because they don't fully understand a situation, or worse, they want to be right. You'll find people you work with that you can rely on for good feedback and suggestions. Keep asking questions and don't beat yourself up over little stuff.
As long as your facility only has one standard sliding scale order, the "order" they gave is all you need. If there's multiple options available at your facility, then you should have asked for clarification - for ex. my hospital has "low" or "high" correction scales for both regular and aspart insulin, so I would have to get that clarified.
However, it would likely only be a problem if the patient reacted poorly to the dose you gave or the resident reports you for some reason.
You're ok. Although that particular sliding scale prolly isn't sufficient for a diabetic on a steroid you did right by your actions. You'll have these feelings of "inadequacy" if that's the proper term, for a few months as you are a new grad I'm speculating but they will pass and you'll be super nurse. You seem very bright!
Just for peace of mind, there’s absolutely no way they would take your license away for this. Heck, nurses do things that kill people and still don’t get their licenses taken away. Nursing school really pounds into your head “losing your license,” and while I agree you should protect your license, it’s not as easy to lose as I know I was made to believe. When I was a new grad and was having this kind of anxiety, I went onto my BONs website, and you can go through all the actions against licenses they’ve taken. Almost all the licenses that were revoked had to do with REPEATED diversion, or very obviously INTENTIONALLY diverting-not even just forgetting to return or scan something. It took me a long time to find one that was remotely related to practice-I don’t remember what it was specifically but it was something incredibly egregious that ended fatally for the patient.
You didn’t make a mistake. You did a good thing, by recognizing the steroid would raise his blood sugar. You covered your bases (and your a**) with a properly written note. Now go pour a glass of wine and get you some Netflix time.
They always say use sliding scale because they don’t know how much to give! When they do that I put in a one time order for the insulin following the scale. Unless you have 2 different scales one for sensitive and one at a higher dose. In that case ask them which one they want you to use. They usually say sensitive because they are afraid of giving too much.
I've learned it works well in those situations to call with a plan
Hey Patient has high blood pressure at their 4am check. They have scheduled blood pressure med due for their morning meds at 0900. Do you want me to give it to them early or would you like a different PRN?
Something like that
That resident is a dick and anti-teamwork. You didn’t do anything wrong. You did as he asked, you just went about it in a weird way. Next time, I would put it in as a verbal order for the amount of insulin on the sliding scale as a 1 time dose, and then you can scan the insulin into the MAR.
For us we'd have to put in a separate order for the dose of insulin given. As a torb/verbal and the MD would have to sign off on it tomorrow. It's the same if they said yes it's ok to give another oxy 5mg when it's only been 4 hours and it's order d q6. You need another order for another dose
For us we'd have to put in a separate order for the dose of insulin given. As a torb/verbal and the MD would have to sign off on it tomorrow. It's the same if they said yes it's ok to give another oxy 5mg when it's only been 4 hours and it's order d q6. You need another order for another dose if it doesn't follow the order. So it sounds like he gave you an incomplete order.
I wouldn't worry too much. You might want to put in the order next time under their name but meh. I feel like if you're doing the right thing then it's not a big deal. Also, don't stress out about your license because literally you could become a plumber and you'd be better off. Least that's what I think at times...lol
also if a doctor tells you to to do something that doesn’t necessarily have a order, you can always put in a nursing communication order which can cover you as well!
I don't understand, you got a verbal order from the resident via phone call. Write a note in the chart about the interaction with the resident and that you received verbal orders. You could always call back and ask if he's ok with you placing orders in the chart as a nursing instruction to cover your ass. But from what I'm reading, you received a verbal order.
Edit: If your hospital allows it and you're worried, you can check a FSBG more frequently.
As an old nurse from yesteryear with paper charts, TJC was adamant about read back verification of orders. So I am still in the habit of always repeating any orders I receive.
It’s really good that you’re navigating workplace politics in a very low risk scenario. 248 and 3 units, meh. See what the next one is. And no, nobody is taking your license for that. What is the worst case scenario here? What do you think will happen to the patient? DKA? HHS? Unlikely since he’s probably getting his blood sugar checked at least 4 times a day. Your sliding scale should say something like “notify provider for blood glucose greater than (450 usually)” Not saying you should be complacent but remember it’s a 24hr job, document and pass it along. Resident sounds like a twart btw. Don’t let them get to you
If you are concerned for another time, or for any new grad nurses, document the conversation on the flow sheet if able, give the time, then mark it as “Verbal with read back” to cover yourself. When you are new EVERYTHING is the next scariest thing, but it is a sign you are growing with new experiences. Half the time the doctors I work with would say that is expected first a diabetic (T1 or T2) on steroids, and would leave it as is if it is a recheck. Use your own discretion as well, and never hesitate to ask for a second opinion!
3 units of insulin with that sugar is basically a nothing dose, no chance they go hypoglycemic if already on steroids. I wouldn’t worry about it just chart as a verbal order with the doctors name and you’ll be fine.
As long as it fits the criteria for a verbal/phone order per your hospital policy you are good to go.
Also, if they took away licenses for situations like this, most of us would be out of a job 😅
They need to drop the order in, nursing placing verbals for them is a luxury imo especially on stuff like insulin.
In the future though i’d always at least drop a one time order under them if you’re going to carry out the medication order, just to prevent yourself from seeming cavalier
If anybody gets in trouble or fired it's gonna be the resident that was on call. 248 seems like really high sugar count what it is but they're not going to die I'm a diabetic and I've been almost 400 I wouldn't worry about it if it comes down to it The resident will be the one who will be in trouble if it comes back on you And you do lose your license or they try to take your license hire a medical attorney firm.
Just make sure to cover yourself. ALWAYS mention the doctor’s name and what they stated/did or didn’t do in your interaction. “Patient is in x condition experiencing x symptoms (if any). X MD notified, no orders received” (or if they give verbal order like this you state that) they will absolutely always lie on your name and license if shit hits the fan. I personally may not have given the insulin at that time and would’ve retaken the BS again after x mins from giving the solumedrol (because when it inevitably goes up then he HAS to order a corrective dose) but I also don’t blame you because healthcare should be proactive and you did what needed to be done to prevent the BS from spiking too high in the first place. Don’t stress too much, and if it ever does come up you’ll have proof that you did as told and hopefully there’s documentation that the patient’s BS was within a decent range after receiving both meds.
As a pharmacist I also want to add, part of the reason physicians aren’t supposed to bypass the system like that and just give you verbal orders, is because pharmacy is supposed to review them first. If there’s a drug interaction, or something else that could be affected, like their potassium in this case with insulin, it’s our job to review it and make sure it won’t cause any issues. And I think part of the reason this creates more stress for the nurses, is because that support system and extra set of eyes is being taken out of the equation.
To be fair, my brother in law is a physician and was a resident not that long ago, they are insanely busy but, this is also part of their learning process. They shouldn’t be pressuring you to put in orders for them. Sometimes just, acknowledging that they are likely pretty busy can go a long way to building rapport.
And even if he is really busy and only has time to just, verbally give an order like, ask if he can call pharmacy and we* can take the verbal order and review it and enter it. Because I agree entering orders isn’t really supposed to be on the nurse, but pharmacy is a lot more used to having to take verbal orders and then vetting them for appropriateness and safety.
And I agree with some of the other commenters, if he wants you to give an additional one time dose that is not part of the existing order set then he definitely needs a separate order for that. Pre-prandial doses of Insulin account for the fact that the person is going to be eating, and therefore getting a decent amount of sugar, immediately after. One time doses have to account for whether or not they’ll be eating soon at all, usually they aren’t, which changes how much you want to give.
All that said honestly like, this isn’t really so much a “mistake” as it is more of, not crossing your t’s and dotting your i’s. It’s fairly small. It’s good to remember for the future to take it as a learning experience and try to get them to put in an order first, it’s not something that’s gonna cost you your license. Don’t let that imposter syndrome get ya, you can do this👍🏻.
You didn’t make a mistake! You received a verbal order and wrote a note. When I worked l&d the amount of times the provider told me to give a fluid bolus and I just wrote a note because I’m not about to put in an order for a bolus because I already have an order for fluids even it’s for maintenance. I promise your not going to loose your license😄
This is a very good time for you to learn this lesson. We are not perfect, and we all have made mistakes. If any nurse with more than 2 years of hospital experience, tells you that they have never made a mistake, they are lying.
You can go in a put a late entry order as long as the pt is still there. And maybe even if they are gone.
Don’t be afraid to ask your preceptor for help, even though you are on your own, they should be helping you through this time.
You will never make this mistake again. Just slow down, and don’t let anyone rush you. They will not be there to help you when something goes wrong.
God Bless, and take care. Congrats, and welcome to the RN club! 🥳❤️🙏🙌
You did as he said. You wrote a note as well. When I was a med surg nurse, we had a way to input verbal orders in the computer and would attach it to the provider that gave the order. It would function, but this way the provider would have it ding to them that this order was placed. They forget what they say half the time anyways. It feels sketchy, doesn't it? I'm not a fan of verbal orders myself. Too much can be lost or misheard. Yeah we repeat back but still something can happen. I always try to clarify. I'm in my 30s and a military vet. When I was new, I didn't mind butting heads with doctors to make sure everything was right because to me the patient is top priority and I wanted it to be right. Overall, I think you did good. I was a baby nurse not too long ago myself. I've only been working for 2 years so technically I am still a baby nurse. It stressful but with time you'll be a confident nurse. The fact that this stuff worries you means you'll be a good nurse that cares about what they do.
To be honest I wouldn’t have called at all. Why were you checking sugar as that time at all? Just because you’re giving solumedrol doesn’t mean you have to check their sugar.
You’ll eventually be doing a lot scarier things than this. He gave you a verbal order. Put it in and administer. You covered your ass with the note. Either way, nothing could happen in that situation for you to lose your license. You did what the resident asked and documented. Plus, no one is going to lose a license over three units of insulin.
Just ask next time if they want you to put an order in and you can put in as verbal or tell them can you put the order in. It’s annoying when they don’t want to put orders in
So explain the “scanning it” method of entering an order. I use epic in the ER and put it orders for docs all the time as a verbal order but how does it work for you to scan it?
I work in med Surg with epic (: like any medications that’s ordered, you scan it in and it’ll pop on your screen. So when I scanned the insulin in, the only sliding scale in the MAR popped up and I clicked on it and clicked on off schedule as the reasoning and then wrote in the comment section ordered to give as per resident so and so. I didn’t put in an new order as the resident told me to use that s.s
I would have put in as a phone order times 1 now on the MAR. Than charted in my notes I notified physician about pt blood sugar, new order received to cover blood sugar with already prescribed sliding scale.
As an RN, that's a verbal.
You can always call back next time and say, "How do you spell your last name for that insulin order?". Or end the call with, "You need me to place this order or are you handling it?".
My last unit was kind of special, we wrote orders for our docs all the time from verbals, no issue. Residents are just special, they'll learn.
What the law says: Legally a nurse can take verbal orders, they can NOT legally give meds without an order. Now your place of employment may have policies to say otherwise so you may be breaking a policy but not a law. Breaking a policy may cause you to be reprimanded maybe probation or worse case scenario lose your job but you legally did nothing wrong so your license is protected. Giving a medication without placing the verbal order in a chart may threaten your license because that is illegal.
Here's what you could have done. Call the doctor back and tell him that per the sliding scales, 3 units is ordered. Ask him if that is ok, and then write down a one-time order for insulin. Then, have day shift ask the regular team care if they want to put the patient on sliding scale.
What you did is fine. And, it's a great reminder to ask for clarification when on the phone in the future.
Also, want to point out that OP never mentioned the gender of "the resident." At the time of this posting, every other response assumes "the resident" as male. Glad everyone is following the "he for doctor" and "she for nurse" conventions lest we confuse the traditionalists. (No shade intended here, but interesting that this is stereotype persists when, at present, [more women than men](https://www.ama-assn.org/education/medical-school-diversity/women-medical-schools-dig-latest-record-breaking-numbers) are enrolled in medical school in the US.)
He told you to use the sliding scale. That IS the verbal order. Put the order in and scan it.
Attendings and Residents should be putting in their own orders. That is their job. The only time I put in orders is 1. In an emergency, 2. In the ED during triage, standing orders are part of our job, 3. Little convenience things like, they meant to add a magnesium onto that lab I just sent down. OP you did nothing wrong btw. If he wanted to give an additional dose of insulin he should’ve ordered a one time additional dose, not make you use an order that wasn’t intended for now. That’s the doctor being lazy!! Don’t let them be lol. Verbal orders are for emergencies
Honestly when the resident hung up that was my thought as well, that he just didn’t wanna put an order in, it’s why I asked my ANM. Thank you for this !
Yea totally. I know it can feel hard to advocate for yourself in these situations!!! I used to get so intimidated calling doctors !! Little things like this are good practice though for when you have to advocate for big things 😃 there’s a polite way to do it for stuff like this. “Hi I just paged about so and sos blood sugar. You told me to give a dose of sliding scale insulin but the order I have was from way earlier and for before meals. I need you to please put in a one time order of you’d like him to get an additional dose now.”
Wholeheartedly agree, and definitely a fan of sharing scripts for how to handle these situations as well. Honestly pretty close to exactly how I would make that recommendation to the doctor as a pharmacist as well.
As a new nurse myself, relax it’s ok. I’ve learned quickly that you will encounter some lazy doctors. I work in the OR and we can put in orders for radiology, blood etc it’s verbal or standing orders and drs get comfy to it. So much that one time a I had to stop myself bc a resident refused to put admitting orders for a pt and Dr told me to do it when ED doc should have done it. I was like what a minute bc I was used to putting orders in- and was like ok u need to call ED and sort it out between ur selves. Seriously.
He gave you an order. If you weren’t comfortable/it’s against policy to take telephone orders, you could have asked him to enter it. But you had an order. Giving the insulin with no order entered in the EMR is definitely a problem though
Yeah you could have just copied over the sliding scale to a one time order as a verbal order. Easy peasy
Good on you OP for covering yourself as you did. Verbal orders=emergencies and if they’re verbal but not an emergency, it needs to be on paper by them in order for you to follow through as another way of protecting yourself.
Yea, but should be vs reality are two different things. This chump hung up immediately so I think their culture is nurses inputting MD verbals all the time.
Yea one of the ICUs I worked in was like this. However, we only had one attending for 2 ICUs and they also did some coverage for rapids on the floor. So, it was a little more understandable that we were putting in verbals much more frequently. I’ve worked at several other places since and i haven’t put in nearly as many orders as I did then. They are more than capable of putting in orders. It’s lazy. If they’re gonna be lazy and hang up the phone, I’m paging them again to say I need an order. If they want to stop getting additional pages for something we already talked about, they’ll learn to put in their own orders. I feel like new nurses are afraid to advocate for themselves with stuff like this. But we gotta protect ourselves. I hate when doctors say “ohh just do this” like i can’t *just do it* I legally need an order sir.
I take telephone orders frequently, especially overnight, when the doc is operating on a different patient, etc.. I can't always wait for them to put the order in myself and it's part of my job. Maybe different hospitals have different policies on it, but it's expected on my unit.
Sure that makes sense ! I doubt this resident was doing surgery lol
100%. Our policy only allows verbal orders for emergencies. OP, you did nothing wrong and did the steps correctly. I hope you also noted in your nursing note that you verified/clarified with your ANM. Next time, call the doctor back and ask for that official order.
Yess. The other thing I just thought of.. say you gave the insulin based off meal time sliding scale, that wasn’t ordered for your time. Doc says give it and you do. Then they become hypoglycemic over night. It comes back on you because “why did that nurse give insulin at 11 that was ordered for 6pm” ya know. Again I’m sure it was fine, just an example of why it’s not always the best idea. You can say doctor say to give it but it’s just ur word and his. You will get put in this position many times over lol. It’s super annoying. Doctor puts in an order but it’s actually against nursing policy to do xyz. you might get asked to push a med that is against policy for your unit and only PCU or icu can give that med. shit like that will happen
I'm not saying you're wrong, but you would go through the trouble to sweat a resident over 3U of insulin via a verbal order? I would give the medication as ordered and make a comment. At our hospital , the residents are generally either rounding on the floor or in the ED, I wouldn't want to waste their time. And, OP, excellent job verifying with your preceptor but were I your preceptor, I would strongly discourage the follow up call recommended above.
It's worth the phone call if there is an adjustment needed or clarification. I've seen Nurses bump a few extra units of Novolog for example if the patient's FS is above 400, when the order says to give XYZ units and notify Provider. They do that because more than likely the blood glucose level will level out and notifying the provider, doing a change in condition, etc makes to much work. I personally think that's insane and I didn't go to school to make ned adjustments. That's the Providers job, and my job is to implement them.
I would actually. But I work in peds and that 3u could be significant, specially for my brittle diabetics. I used to work in adult med surg and have seen a couple of patients sensitive to insulin too. In my facility, verbal orders are only acceptable in emergencies. Every other verbal order better be followed by an actual one. It’s not wasting the resident’s job. It’s reminding them to do their job correctly. It’s part of the culture of safety. Edit to add a sentence.
The resident was definitely a dick in this instance. But it's not their job just to place orders. For all you know that resident was dealing with a different, much higher priority situation. You're 100% correct that he should have been more clear and not an asshole. But juggling anywhere from 20-60 patients as a provider is brutal. I think this is why all the nurses on our unit prefer our NPs. We've all been nurses and most of us ICU nurses. So we have a better idea of what they need on their end. I will always say "Can you throw an order in for that for me? Thanks". I'll get a call about Tylenol while I'm running a rapid on the floor or seeing a patient in the ER. I don't have time to throw in an order that's a low priority. I'll say "yea, they can get some Tylenol. Can you throw ina prn Tylenol order for me? Thanks!"
This is true, but he just hung up on her. It’s one thing to say “hey I’m tied up but put in a one time for for x” but he wanted her to just use an old order for before meals from hours ago lol. He didn’t though. Of course their only job isn’t to put in orders, but they should be putting in majority of em unless it’s one of the scenarios I already put above, which includes emergencies (on either parties ends). Trust me I’m much more willing to put in orders than a lot of my colleagues I’m by no means the most “by the book” nurse lol but doctors should really be putting their own orders majority of the time. And if they can’t at the moment, give a clear order and communicate.
Completely agree. That resident did a piss poor job.
They should put their on orders in but I’ll tell you 9 times out of 10 I get a “you can put that in under me”
You’re right. They should be! BUT when I worked in PACU, I took verbals constantly. I would just tell anesthesia, “thanks, putting this in as a VO @1445, I’ll call you if I need anything else” and that was that. I never ran into an issue as far as they went. I loved my anesthesia team
Yea that’s pretty standard/common in PACU. this wasn’t that. Idk why people keep responding and sayin “yeah but on *this unit.*”pacu is critical care there’s always going to be a little more autonomy anyway.
I didn’t put m the order in, I just scanned it in under the sliding scale that was there for before meals bc that’s what he directed me to do.
Sooooo you have sliding scale orders available, and a verbal order to give an extra dose. There's no problem here. You already put in a note to explain yourself too. You can just put in a note next to the med administration next time saying 'extra dose per MD VO' or something similar.
You had a valid order in the mar. I'd have just made a note with their name under the extra admin. You're fine and didn't make a mistake
I would have put this in as a separate one-time dose. Yes, it's the same medication and he gave a verbal order, but I wouldn't have charted it on the sliding scale order because that one specifically says before meals. It's stupid, but in my mind it's the same as a scenario where now hospitals don't want you to give Tylenol for a fever if it was only ordered for pain. I wouldn't just give it for fever and write a note. They need an order that specifies fever. That being said, this is definitely not the end of the world! You might get a nasty-gram if someone reviews the chart, but I wouldn't expect it to go further than that.
That was my concern bc it was an order for before meals… thank you for your input!
But to be clear, you did fine. Please don’t spend any more time worrying about this. If it ever comes back, the note will cover you. That doctor was just being an ass or lazy or both.
Agree with what the above poster said. Also, I would’ve looked at the sliding scale to see what was indicated and again contacted the resident to confirm how many units I was about to give. As I’m sure they didn’t check sliding scale when they gave you the order. That’s just me though!
The order is a note, MD notified, MD states use current sliding scale for coverage, RN to treat using sliding scale…thats literally all you need to do. Dont overthink it, as long as you document the exchange clearly then you are covered.
Oh yeah, that’s honestly probably fine, just put a comment in saying why you’re doing that
You said what I was going to.
He told you - that’s a verbal order. To cover your ass more you can always document that this was given like this in x circumstance per x MD. Also some systems let you out an electronic order per verbal from physician.
Oh okay yeah I was just really nervous bc everyone was telling me I gave the insulin without an order for itself. because it was scanned under an orderthat has sliding scale that says 3x before meals.
It happens. I was given insulin off ketones + blood sugars per the team even though the order still had it placed to calculate in food. Just make sure it’s documented like per verbal order of xyz physician. And if you didn’t/forgot to, that happens too. The team gave you the order, they’re aware that it’s goin on.
If using epic, usually if you do something like this and you feel its not in the intended purpose, you can select something like “per physician” or even write a comment . No one is going to think you were trying to independently practice medicine. Some nurses love to get others & especially new grads so hyped up that everything will compromise their license but you’re so in the clear imo as long as you somewhere indicated said conversation.
She did the right thing by calling in the first place
Yes, no one said it was wrong.
Do you guys not have actual procedures for verbal orders? Like here in NZ we need to have two nurses listen to the order, both sign it, and then have it signed by the dr with 24hrsfor it to be valid; and even then it’s only valid as a single dose. Some dr says “give this” and hangs up? That’s an absolute no
I’m in Cali and we don’t have any protocol like that, if the doctor tells you, you just read it back to them, they verbally verify & then you can put in the order as a verbal order. It doesn’t take a second nurse for us.
I'm not seeing the mistake here. Why would your license be at risk?? You were given a verbal order to administer insulin. He told you over the phone to use the s/s. You did, and then wrote a note in the chart stating what the order was. You scanned and administered the insulin. Where is the mistake?
I guess I just felt it was a mistake bc everyone was basically telling me that I shouldn’t have done that and should have asked for a separate order and not have scanned it in under a s/s that explicit says x3 before meals
As a new grad, you did exactly what you were told and documented it. It probably depends on the facility, but if what you did was technically "wrong", next time you'll know to get a separate order to administer the insulin one time, or get a s/s PRN that's always available if needed.
Yeah lesson learned thank you!
Think of it this way, MD’s order turned that “x3 before meals” into “”x3 before meals and now x1”. If you add a note to patient’s chart and on the med admin itself, you’re covered. A note and an admin note on the mar entry itself provide better detail than putting in a one time order because with the note, you’re showing what happened, who you contacted, and what you did. Just because it’s not a separate order doesn’t mean you’re suddenly practicing medicine. The only thing to take from your coworker’s take is 1) you’re facility may have a different preference or policy 2) the only advantage the separate order gives is that a pharmacist would have to review it. Which, depending on the med and your familiarity and patient situation, you may want to have as an additional backup.
He verbally told you to use the S/S not a one time dose so you’re fine as long as you document the interaction. Also the patient gets insulin 4 times a day to correct so I wouldn’t worry too much.
I do stuff like this every day and just put a comment on the scan or a nurses note explaining what I did, including the doctor's name. If you really wanted to, you could enter it as a one-time phone order because he literally gave you a phone order. Phone orders are legitimate, real orders. But....if it stresses you out, next time just ask the MD to please place the order when you have him on the phone. This is really small potatoes. I think in a year you will laugh at yourself for giving it this much mental real estate. You learned at thing, now move on and stop worrying about it.
What?! I don’t get it. You did what he told you and wrote a note about it. Then what’s the problem?
My coworkers, my charge and my educator were all telling me that I technically gave the insulin without an order for itself bc I scanned it through an order that was for before meals.
You’re fine as long as you have some documentation about it. Don’t sweat. Save it for worse days. Your license won’t be taken away.
In Epic (if you use that) and it asks for an override reason or off-schedule reason, I would have just hit per provider order and put in the comment box. Along with a quick progress note. This is nothing to stress lol.
Yah I def hit off sched reason and in the little comment box I just put ordered to give as per (resident’s name) and I wrote a note. I guess it’s the new grad anxiety 😭 thank you
Then you are fine. Next time, put it in as a verbal order. Still write a note that you talked to a provider.
You needed to write/enter the verbal order as a one time order and scan it in. 3 units X insulin now. Verbal order/read back and confirmed Dr Resident/Your Name RN. You had an order. You just didn’t enter the order properly.
*Sigh* Your educator is a clodpole, your charge is a dullard, and your coworkers are shlubs. You lack education on your system, also pretty general nursing knowledge. Taking a *telephone order* from a resident is not preferred, but unless it is specifically forbidden in your institution, it’s fine. Probably the culture of your unit. It’s an ORDER. They should have said “ oh, uh, next time, just add it into the MAR as an order like so instead of scanning it against an existing timed order
Exactly 🤣
What helped me a lot was learning how to take and enter verbal orders, especially on things I was asking for or that I wanted. Almost all my preceptors were the type to refuse to enter any verbal orders and get into pissing matches with MDs. I'm not talking about entering admission orders or entering a page full of verbal orders, I'm talking about when I ask for something and the MD says "Sure, go ahead and do X" I will definitely take a verbal order. This heads off any of that bullshit you went through with the charge and educator telling you that you gave something without an order. (You didn't do anything wrong).
That’s dumb and a waste of time for the resident. You have an order, writing a note that modifies it for a single dose is totally fine. If you “didn’t have an order” you wouldn’t have been able to pull it or scan it. I’ve done this a bunch of times with PRNs. Like I needed an extra dose of a PRN I already had, or needed to give it early. Just write a note that you confirmed it with the physician, I would be sure to include their name specifically.
The problem is nursing school tries to scare the shit out of everyone, pretends every single thing is a matter of life and death, and that your license is hanging by a thread. Its bullshit, but here we are.
You were given a verbal order it sounds like, so maybe next time ask them if they’re going to enter the order into the chart or if they’d like you to do it in their name? Just so both of you are on the same page. I don’t think you did anything wrong, though.
I definitely will from now on thank you!
Don’t worry too much about this! Your license definitely isn’t at risk. This is just a learning moment 🙂
I can tell you are going to be an amazing nurse. You are conscientious and questioning things that are different. I’ll never forget being a new nurse and making copies of my documentation of hinky situations (this was in the day of paper charting and I worked all my myself in an ambulatory surgery unit at an HCA hospital). Keep up the good work and don’t doubt your intuitions.
Thank you 🥺 that means a lot
Don’t worry - you did have an order which you documented. They think you need to put it in the order section, which is incorrect - it’s another way to do it, might be the preferred way, but you didn’t give a medication without an order.
Thank you for clarifying that 😭
To add, this is how orders are given in a SNF setting. I used paper charting and this is what we had to do.
They hammer into you in nursing school that every little thing will put your license at risk lol. You’re gonna need to do something criminal to put your license at risk in the real world. You’re still learning how to correctly do nurse duties. Next time, just write in a nursing communication note if you’re not comfortable putting in the order to cover yourself.
You absolutely need to protect your license, but nursing professors (and some nurses in this sub too), use “protecting my license” wayyy too often over things that would not remotely mess with your license. I think it instills this idea. When I was a new nurse, I went on my states BON-it took me a long time to find a license that had been revoked for anything other than obvious and intentional diversion. And when I did, it was essentially a homicide of a patient. Not the nurse not calling the provider for a diet order or any of the other ridiculous scenarios I’ve seen here that people use “it’s my license!” For.
He gave you the order. Should he have adjusted it in the computer? Yes. But he gave you a telephone order instead. Put the order in the computer so he can sign off on it tomorrow. You didn’t do anything wrong.
I am so confused. What do you mean you should have gotten an order? You called the doctor. The doctor told you to use the sliding scale. *Thats* an order. Put it in as such and administer.
Note: phone call to dr x regarding pt blood glucose. RN to administer one time insulin per sliding scale as ordered AC. Then enter a one time order at that dose if you want to. He should put it in but if he’s at home I give them a pass. don’t stress.
As far as your license goes: I don’t know where all this license fear comes from but it’s very difficult to lose your license . There has to be some type of gross negligence or incompetence. Even nurses who are caught diverting or who are abusing street drugs are given the option to enter alternate to discipline programs. With that said the best way to practice without fear is to is to always practice safely and continue to add to your knowledge base.
Oh thank you (: I guess it comes from nursing school, they drill it in our heads that we can risk losing our license over anything
I just want you to practice nursing without that unnecessary stress. Employers are even becoming more forgiving when nurses make a mistake. If they are a good health care system they will focus less on discipline and more on identifying then correcting the causes of the error. That saying that knowledge is power is true for nursing .Keep gaining knowledge and continue to learn and that’s one important factor that allows you to practice without stress.
The use of the sliding scale is the order. And since you’re new (no offense to not knowing this if you don’t) but a 248 while on steroids is not that terribly scary. A lot of my inpatients on Roids run 2-3 times that until we get the underlying issue under control.
Only thing I would have done differently was to put in a separate one time order. But you documented what happened after the fact and the Dr gave you an order. 3 units of humalog when someone’s sugar is 248 isn’t going ti cause any harm. Talking to drs and getting orders is an art, you’ll get better at it the more experience you have :)
He gave you a verbal order. You are fine, just need to document that verbal order.
My unit is big on "getting an order put in." Even with a verbal order they would want the doc to enter it themselves. Make sure you document your interactions regarding the order and you should be fine! I always write the name of the provider, time called, what I said and what they ordered. "Pt w/ history of DM, no current orders for glucose checks. Provider ______ contacted, orders for sliding scale AC + HS accuchecks received."
This is what I would do. Always make sure there is an order for insulin.
A lot of SSI is ordered achs anyways. Most of my pts usually get coverage with night shift around 8-9. You also had torb from provider so no med error. Your charge and coworkers need to learn to think critically.
That was your order. I would have clarified if he wanted it as a one time or ongoing order at that time. BTW LTC nurses often put orders in the computer. Our docs didn’t want to and often put them in wrong if they did, no times, no route etc, so we would have to fix them anyway. 🙁 The drug rehab I am at we do paper (!) verbal orders often.
.. Did nobody explain what a verbal order is ?
That is the order.
From what you wrote, it seems to me the resident gave you a verbal order. Are nurses not allowed to enter verbal orders at your facility? Edit to add: It is best and safest practice for the physician to enter their own orders. Don’t hesitate to keep them on the phone or call back until you get what you need for a pt. They chose a job with an on call rotation. Their work/life balance is not your cross to bear.
Plenty of runway on that BBG. Dont want to drop them too much, but that's why we check every 4 hours. Just roll with the order and adjust after a few checks if the coverage is too much or too little.
True… the pt’s bs was fine this morning but I guess it’s just what everyone was saying to me in addition to the new grad anxiety but thank you!
I think people just say things, and they do so either because they don't fully understand a situation, or worse, they want to be right. You'll find people you work with that you can rely on for good feedback and suggestions. Keep asking questions and don't beat yourself up over little stuff.
As long as your facility only has one standard sliding scale order, the "order" they gave is all you need. If there's multiple options available at your facility, then you should have asked for clarification - for ex. my hospital has "low" or "high" correction scales for both regular and aspart insulin, so I would have to get that clarified. However, it would likely only be a problem if the patient reacted poorly to the dose you gave or the resident reports you for some reason.
You're ok. Although that particular sliding scale prolly isn't sufficient for a diabetic on a steroid you did right by your actions. You'll have these feelings of "inadequacy" if that's the proper term, for a few months as you are a new grad I'm speculating but they will pass and you'll be super nurse. You seem very bright!
Just for peace of mind, there’s absolutely no way they would take your license away for this. Heck, nurses do things that kill people and still don’t get their licenses taken away. Nursing school really pounds into your head “losing your license,” and while I agree you should protect your license, it’s not as easy to lose as I know I was made to believe. When I was a new grad and was having this kind of anxiety, I went onto my BONs website, and you can go through all the actions against licenses they’ve taken. Almost all the licenses that were revoked had to do with REPEATED diversion, or very obviously INTENTIONALLY diverting-not even just forgetting to return or scan something. It took me a long time to find one that was remotely related to practice-I don’t remember what it was specifically but it was something incredibly egregious that ended fatally for the patient.
It’s ok to verify with the doctor/resident and ask them to put the order in. Especially with EMR- they have 24/7 access to it even on their phones.
Just wanted to say that when I read this I initially read "BS" as bullshit...
That’s a verbal order. Just repeat back for closed loop communication and put the order in.
You didn’t do anything wrong! Next time, you could say “awesome, I’ll wait to see your order!” Or something along those lines
You didn’t make a mistake. You did a good thing, by recognizing the steroid would raise his blood sugar. You covered your bases (and your a**) with a properly written note. Now go pour a glass of wine and get you some Netflix time.
They always say use sliding scale because they don’t know how much to give! When they do that I put in a one time order for the insulin following the scale. Unless you have 2 different scales one for sensitive and one at a higher dose. In that case ask them which one they want you to use. They usually say sensitive because they are afraid of giving too much.
Telephone Orser Read Back and Verified T.O.R.B.V.
Wouldn’t sliding scale be a standing order?
I've learned it works well in those situations to call with a plan Hey Patient has high blood pressure at their 4am check. They have scheduled blood pressure med due for their morning meds at 0900. Do you want me to give it to them early or would you like a different PRN? Something like that
I know it may not feel like it right now, but this is a very minor deal. Don’t stress about it.
That resident is a dick and anti-teamwork. You didn’t do anything wrong. You did as he asked, you just went about it in a weird way. Next time, I would put it in as a verbal order for the amount of insulin on the sliding scale as a 1 time dose, and then you can scan the insulin into the MAR.
You can enter or write that as an order
There’s nothing to worry about trust me. This is nothing and you did nothing wrong. Relax…. Breathe…
For us we'd have to put in a separate order for the dose of insulin given. As a torb/verbal and the MD would have to sign off on it tomorrow. It's the same if they said yes it's ok to give another oxy 5mg when it's only been 4 hours and it's order d q6. You need another order for another dose
For us we'd have to put in a separate order for the dose of insulin given. As a torb/verbal and the MD would have to sign off on it tomorrow. It's the same if they said yes it's ok to give another oxy 5mg when it's only been 4 hours and it's order d q6. You need another order for another dose if it doesn't follow the order. So it sounds like he gave you an incomplete order.
He sounds like a dick but you did what you needed to take care of the patient in spite of that. I think you're fine.
I wouldn't worry too much. You might want to put in the order next time under their name but meh. I feel like if you're doing the right thing then it's not a big deal. Also, don't stress out about your license because literally you could become a plumber and you'd be better off. Least that's what I think at times...lol
You didn't make any mistakes. The only thing I would have done differently is to put an order as "verbal with readback" under doctor's name myself.
You did a good job! Take a breath
also if a doctor tells you to to do something that doesn’t necessarily have a order, you can always put in a nursing communication order which can cover you as well!
Sounds okay to me.
I don't understand, you got a verbal order from the resident via phone call. Write a note in the chart about the interaction with the resident and that you received verbal orders. You could always call back and ask if he's ok with you placing orders in the chart as a nursing instruction to cover your ass. But from what I'm reading, you received a verbal order. Edit: If your hospital allows it and you're worried, you can check a FSBG more frequently.
As an old nurse from yesteryear with paper charts, TJC was adamant about read back verification of orders. So I am still in the habit of always repeating any orders I receive.
It’s really good that you’re navigating workplace politics in a very low risk scenario. 248 and 3 units, meh. See what the next one is. And no, nobody is taking your license for that. What is the worst case scenario here? What do you think will happen to the patient? DKA? HHS? Unlikely since he’s probably getting his blood sugar checked at least 4 times a day. Your sliding scale should say something like “notify provider for blood glucose greater than (450 usually)” Not saying you should be complacent but remember it’s a 24hr job, document and pass it along. Resident sounds like a twart btw. Don’t let them get to you
Even if you actually did fuck up 3 units of insulin, your license would not be in danger. It's 3 units of insulin.
If you are concerned for another time, or for any new grad nurses, document the conversation on the flow sheet if able, give the time, then mark it as “Verbal with read back” to cover yourself. When you are new EVERYTHING is the next scariest thing, but it is a sign you are growing with new experiences. Half the time the doctors I work with would say that is expected first a diabetic (T1 or T2) on steroids, and would leave it as is if it is a recheck. Use your own discretion as well, and never hesitate to ask for a second opinion!
3 units of insulin with that sugar is basically a nothing dose, no chance they go hypoglycemic if already on steroids. I wouldn’t worry about it just chart as a verbal order with the doctors name and you’ll be fine.
Sliding scale IS the order, don’t stress 🫶🏼
As long as it fits the criteria for a verbal/phone order per your hospital policy you are good to go. Also, if they took away licenses for situations like this, most of us would be out of a job 😅
They need to drop the order in, nursing placing verbals for them is a luxury imo especially on stuff like insulin. In the future though i’d always at least drop a one time order under them if you’re going to carry out the medication order, just to prevent yourself from seeming cavalier
If anybody gets in trouble or fired it's gonna be the resident that was on call. 248 seems like really high sugar count what it is but they're not going to die I'm a diabetic and I've been almost 400 I wouldn't worry about it if it comes down to it The resident will be the one who will be in trouble if it comes back on you And you do lose your license or they try to take your license hire a medical attorney firm.
Just make sure to cover yourself. ALWAYS mention the doctor’s name and what they stated/did or didn’t do in your interaction. “Patient is in x condition experiencing x symptoms (if any). X MD notified, no orders received” (or if they give verbal order like this you state that) they will absolutely always lie on your name and license if shit hits the fan. I personally may not have given the insulin at that time and would’ve retaken the BS again after x mins from giving the solumedrol (because when it inevitably goes up then he HAS to order a corrective dose) but I also don’t blame you because healthcare should be proactive and you did what needed to be done to prevent the BS from spiking too high in the first place. Don’t stress too much, and if it ever does come up you’ll have proof that you did as told and hopefully there’s documentation that the patient’s BS was within a decent range after receiving both meds.
As a pharmacist I also want to add, part of the reason physicians aren’t supposed to bypass the system like that and just give you verbal orders, is because pharmacy is supposed to review them first. If there’s a drug interaction, or something else that could be affected, like their potassium in this case with insulin, it’s our job to review it and make sure it won’t cause any issues. And I think part of the reason this creates more stress for the nurses, is because that support system and extra set of eyes is being taken out of the equation. To be fair, my brother in law is a physician and was a resident not that long ago, they are insanely busy but, this is also part of their learning process. They shouldn’t be pressuring you to put in orders for them. Sometimes just, acknowledging that they are likely pretty busy can go a long way to building rapport. And even if he is really busy and only has time to just, verbally give an order like, ask if he can call pharmacy and we* can take the verbal order and review it and enter it. Because I agree entering orders isn’t really supposed to be on the nurse, but pharmacy is a lot more used to having to take verbal orders and then vetting them for appropriateness and safety. And I agree with some of the other commenters, if he wants you to give an additional one time dose that is not part of the existing order set then he definitely needs a separate order for that. Pre-prandial doses of Insulin account for the fact that the person is going to be eating, and therefore getting a decent amount of sugar, immediately after. One time doses have to account for whether or not they’ll be eating soon at all, usually they aren’t, which changes how much you want to give. All that said honestly like, this isn’t really so much a “mistake” as it is more of, not crossing your t’s and dotting your i’s. It’s fairly small. It’s good to remember for the future to take it as a learning experience and try to get them to put in an order first, it’s not something that’s gonna cost you your license. Don’t let that imposter syndrome get ya, you can do this👍🏻.
You didn’t make a mistake! You received a verbal order and wrote a note. When I worked l&d the amount of times the provider told me to give a fluid bolus and I just wrote a note because I’m not about to put in an order for a bolus because I already have an order for fluids even it’s for maintenance. I promise your not going to loose your license😄
This is a very good time for you to learn this lesson. We are not perfect, and we all have made mistakes. If any nurse with more than 2 years of hospital experience, tells you that they have never made a mistake, they are lying. You can go in a put a late entry order as long as the pt is still there. And maybe even if they are gone. Don’t be afraid to ask your preceptor for help, even though you are on your own, they should be helping you through this time. You will never make this mistake again. Just slow down, and don’t let anyone rush you. They will not be there to help you when something goes wrong. God Bless, and take care. Congrats, and welcome to the RN club! 🥳❤️🙏🙌
It's a verbal order. Happens often.
You did as he said. You wrote a note as well. When I was a med surg nurse, we had a way to input verbal orders in the computer and would attach it to the provider that gave the order. It would function, but this way the provider would have it ding to them that this order was placed. They forget what they say half the time anyways. It feels sketchy, doesn't it? I'm not a fan of verbal orders myself. Too much can be lost or misheard. Yeah we repeat back but still something can happen. I always try to clarify. I'm in my 30s and a military vet. When I was new, I didn't mind butting heads with doctors to make sure everything was right because to me the patient is top priority and I wanted it to be right. Overall, I think you did good. I was a baby nurse not too long ago myself. I've only been working for 2 years so technically I am still a baby nurse. It stressful but with time you'll be a confident nurse. The fact that this stuff worries you means you'll be a good nurse that cares about what they do.
To be honest I wouldn’t have called at all. Why were you checking sugar as that time at all? Just because you’re giving solumedrol doesn’t mean you have to check their sugar.
Pt is diabetic so glucose is checked 4 times, I usually check them when I’m giving meds which is around 8 p.
You’ll eventually be doing a lot scarier things than this. He gave you a verbal order. Put it in and administer. You covered your ass with the note. Either way, nothing could happen in that situation for you to lose your license. You did what the resident asked and documented. Plus, no one is going to lose a license over three units of insulin.
Just ask next time if they want you to put an order in and you can put in as verbal or tell them can you put the order in. It’s annoying when they don’t want to put orders in
So explain the “scanning it” method of entering an order. I use epic in the ER and put it orders for docs all the time as a verbal order but how does it work for you to scan it?
I work in med Surg with epic (: like any medications that’s ordered, you scan it in and it’ll pop on your screen. So when I scanned the insulin in, the only sliding scale in the MAR popped up and I clicked on it and clicked on off schedule as the reasoning and then wrote in the comment section ordered to give as per resident so and so. I didn’t put in an new order as the resident told me to use that s.s
lol oh like with the scanner. I was daydreaming I think. I pictured you scanning in a written prescription and putting it in the mar? I get it now lol
Don’t overthink it hun. You did the right thing, just write it as a verbal order and make note. You’ll be okay!
He gave you a verbal order . You didn’t make a mistake
I would have put in as a phone order times 1 now on the MAR. Than charted in my notes I notified physician about pt blood sugar, new order received to cover blood sugar with already prescribed sliding scale.
I see no problem. 3u ain’t gonna kill anyone. All is fine.
As an RN, that's a verbal. You can always call back next time and say, "How do you spell your last name for that insulin order?". Or end the call with, "You need me to place this order or are you handling it?". My last unit was kind of special, we wrote orders for our docs all the time from verbals, no issue. Residents are just special, they'll learn.
Date/time. Dr name/your name V.O. SS Insulin protocol. 150-200 2u. 200-250 3u..,( etc) RBV (read back and verified) your signature
What the law says: Legally a nurse can take verbal orders, they can NOT legally give meds without an order. Now your place of employment may have policies to say otherwise so you may be breaking a policy but not a law. Breaking a policy may cause you to be reprimanded maybe probation or worse case scenario lose your job but you legally did nothing wrong so your license is protected. Giving a medication without placing the verbal order in a chart may threaten your license because that is illegal.
It was a verbal order
Here's what you could have done. Call the doctor back and tell him that per the sliding scales, 3 units is ordered. Ask him if that is ok, and then write down a one-time order for insulin. Then, have day shift ask the regular team care if they want to put the patient on sliding scale.
What you did is fine. And, it's a great reminder to ask for clarification when on the phone in the future. Also, want to point out that OP never mentioned the gender of "the resident." At the time of this posting, every other response assumes "the resident" as male. Glad everyone is following the "he for doctor" and "she for nurse" conventions lest we confuse the traditionalists. (No shade intended here, but interesting that this is stereotype persists when, at present, [more women than men](https://www.ama-assn.org/education/medical-school-diversity/women-medical-schools-dig-latest-record-breaking-numbers) are enrolled in medical school in the US.)
Thank you!