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As an RN, which leaves me more liable: following hospital policy or a physician’s order? And which is safer for my license?

Monday July 9, 2012
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Question:

Dear Nancy,

Recently, I set up a blood transfusion for a patient. Fifteen minutes prior to the transfusion, her temperature was 97.9. Fifteen minutes after, it was up to 101.8. Hospital policy states that a temperature change greater then two degrees constitutes a transfusion reaction and the transfusion should be stopped and a work-up begun. When I notified the physician, I received an order to continue the transfusion. I followed policy and stopped the transfusion — and got a verbal warning for not following orders. I have had other RNs tell me they have continued the infusion, but documented the order on the chart. As an RN, which leaves me more liable: following hospital policy or a physician’s order? And which is safer for my license?

Marla



Nancy Brent replies:

Dear Marla,

The first question that must be responded to in the situation you describe is "Which is safer for the patient?" As you know blood transfusions are a high risk for the patient. You were right in following the policy governing transfusion reactions. The issue of the physician ordering you to continue the transfusion is where your judgment comes, in terms of following the order or not.

Remember that the nurse is the last line of defense for the patient's safety —there is no one else. So, regardless of a physician order that tells you to continue the transfusion, your assessment of the patient, the recorded vital signs, the policy and your judgment that a continuation of the transfusion was not the correct thing to do was what you followed. As an accountable and professional nurse, you followed your judgment.

Who knows what would have happened had you continued the transfusion and, as your colleagues do, simply "documented the order." What if the patient had died? What if there were harmful effects due to the continuation of the transfusion?

Simply because an order is given and documented does not mean it is to be carried out if your professional judgment tells you otherwise. Yes, there are steps to follow when you make such a reasoned and good faith decision — you document the physician's order and what was said to him or her about not going forward with the transfusion due to the policy and your judgment, contact your immediate superior, document that conversation and fill out an occurrence report, to name a few.

In terms of your license, it would be difficult at best to defend a continuation of a blood transfusion that led to a patient's death before the nursing board. You might be asked to defend yourself for not following the order, or any physician's order, but doing so consistent with standards of practice should result in a favorable response from the board.

It is unfortunate your employer still seems to have the idea that a physician always is right and every order written by a physician must be followed, no matter what. The days of a nurse blindly following a doctor's order have been laid to rest long ago.


Cordially,
Nancy




Nancy J. Brent, RN, MS, JD, is an attorney in private practice in Wilmette, Ill. This information is for educational purposes only and is not intended as legal or any other advice. The reader is encouraged to seek the advice of an attorney or other professional when an opinion is needed.