What do you do when a physician’s order is unsafe?

ED nurses may be held liable

What would you do if a pulmonologist asked you to give a medication subcutaneously when it was approved only for intramuscular injection (IM)?

"I told him I was not comfortable doing this, but he tried to persuade me to do so by explaining why it was safe," says Kathryn Eberhart, BSN, RN, CEN, a Santa Rosa, CA-based legal nurse consultant and ED nurse at Santa Rosa Memorial Hospital.

"I elicited the help of one of the ED physicians who agreed with me, and together we discussed it with the pulmonologist," she recalls. The medication eventually was given IM, and Eberhart documented this in an incident report.

ED nurses often hesitate to question a physician’s order, but nurses are liable in a malpractice suit if adverse outcomes occur as a result, warns Jackie Ross, RN, a Chagrin-Falls, OH-based ED nurse and risk management expert. "Several claims have involved nurses failing to question an order, either a medical treatment or medications," she reports. "Nurses are professionals and will be held accountable for their actions and inactions in a court of law."

Follow these steps if you feel a physician’s order is not safe:

• Use the chain of command.

"If there is an order that a nurse is not comfortable completing, then don’t do it," says Eberhart. "Seek the advice of the charge nurse, and if you are still not satisfied, go up the chain of command."

As an ED nurse, you are the patient’s advocate — and that includes questioning orders that are unsafe or unfamiliar, says Darlene Bradley, RN, MSN, CCRN, CEN, director of emergency and trauma services at the University of California-Irvine Medical Center in Orange.

"If the nurse still feels the order is unsafe, she should refuse to follow-through and let her manager and the physician know why," says Bradley. "If the issue cannot be resolved for instance by an attending physician, the nurse would go up the chain of command and if necessary involve the nursing leadership to mediate."

• Document the incident.

A confidential incident report should be completed if appropriate, but the details of conflicting opinions shouldn’t be included in the patient’s chart, says Eberhart.

After the issue is resolved, the medical record should simply reflect that the previous order was cancelled and a new order was given, says Patricia Iyer, RN, MSN, LNCC, president of Flemington, NJ-based Med League Support Services, a legal nurse consulting firm specializing in malpractice and personal injury cases. "It is not necessary to highlight in detail your concerns after the order is rescinded," she advises.

• Don’t hesitate to speak up.

Research shows that health care professionals are reluctant to voice concerns, even when patient safety is at stake, Iyer notes. "The ED nurse must always remember the responsibility to speak for the patient who cannot speak for himself or herself," she says. "The prescriber needs a safety net — an individual who will detect an error. The nurse is in the position to be that safety net."

She gives the example of a physician about to discharge a man complaining of chest pain, when a nurse intervened by suggesting that he be held in the ED evaluate his cardiac enzymes. "During this observation, the patient’s chest pain worsened, and a decision was made to admit him to the CCU," says Iyer.

When in doubt, research

Remember that distraction, fatigue, and a host of other factors interfere with providing safe orders, says Iyer. "Then you will be able to diplomatically but firmly question an inappropriate order," she says.

If there is any doubt in your mind, seek verification that you are correct, recommends Iyer. "Check a drug dosage using the resources available to you or do a quick Internet search to verify that your concerns are valid, or speak to a more experienced colleague," she says.

Armed with the knowledge that your concern is valid, approach the physician with what Iyer calls an "I" message. For instance, use the following wording:

"I have concerns about administering 10 mg of morphine to this infant. The PDR recommends not exceeding 0.3-0.6 mg/kg per dose. Can we rethink this?" (See box for more examples.)

"This is better than saying, I can’t give this. You give it!’" Iyer says. "Some prescribers may blunder ahead, even in the face of that kind of warning."


For more information on questioning a physician’s order, contact:

  • Darlene Bradley, RN, MSN, CCRN, CEN, Director, Emergency/Trauma Services, University of California-Irvine Medical Center, 101 The City Drive, Route 128, Orange, CA 92868-3298. Telephone: (714) 456-5248. Fax: (714) 456-5390. E-mail: dbradley@uci.edu.
  • Kathryn Eberhart, BSN, RN, CEN, Eberhart Medical Legal Consulting, 4706 Devonshire Place, Santa Rosa, CA 95405. Telephone: (707) 538-7056. E-mail: ebers@sonic.net.
  • Patricia Iyer, MSN, RN, LNCC, President, Med League Support Services, 260 Route 202-31, Suite 200, Flemington, NJ 08822. Telephone: (908) 788-8227. Fax: (908) 806-4511. E-mail: E-mail: patmedleague@yahoo.com. Web: www.medleague.com.
  • Jackie Ross, RN, BSN, 17491 Merry Oaks Trail, Chagrin Falls, OH 44023. Telephone: (440) 708-9813. E-mail: jackieross@adelphia.net.