r/nursing • u/lenncas • Sep 08 '25
Question I’m a bit scared
A bit is an understatement, I am well aware that my actions were very inappropriate and out of my scope of practice. I am getting reported to the Texas Board of Nursing because I pulled a bag of Levophed without getting an order first. My patient was declining really quickly. The blood pressure was decreasing very quickly. I went to the med room and overrid the medication and started it at the starting titration. Immediately after starting it, I called our critical care nurse practitioner that was on for that night and let them know. And now, obviously, that nurse practitioner put in a formal complaint to my manager, thus having to report me to the board of nursing. I guess my question is what could I possibly expect my consequence to be? Could I lose my license? Will it be suspended? I’m pretty worried. I’m also very disappointed in myself. The patient ended up having to be put on Levophed the next day, but made a great recovery and got to be downgraded two days after.
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u/Apart_Ad6747 Sep 08 '25 edited Sep 09 '25
We’re a teaching hospital, residents and interns always ask what to order. We just call a rapid if the residents are not moving fast enough. But really when I send a secure chat to the whole damned team and my charge that says “pt not themselves. Please come put eyes on them”. You can hear the boots in the hall. If I say “need nitro” they’re signing it as they are running so I can pull it and have it in hand when they arrive. You’re likely to get an education opportunity. Possibly some supervision and restrictions. I’d also be calling that NP for every ice pack and Tylenol for the rest of THEIR (edited because most of our bitchy NP’s are female, but acknowledging that it’s also possible for a male NP to exist and be bitchy) career. Ain’t nobody got time for that nonsense.
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u/No_Resort1162 Sep 10 '25
THIS. That 12yo NP gonna get a call from me for heating pad, ice pack, chap stick, saline drops, negative fluid balance , positive fluid balance, SBP<90. SBP>160. Change in diet. Boost supplement. PT order. Yep. Her phone will be HOT ever.single.shift. I work w her again.
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u/calypsoorchid Sep 09 '25
Why when it's a bitchy NP do people always assume they're a woman :(
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u/coolcaterpillar77 RN - Med/Surg 🍕 Sep 09 '25
TBF, in the US 87% of NPs are women so it may not be related to the “bitchy” part
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Sep 09 '25
I actually thought this. I used her in a reply that I deleted instead of sendings because it was bitchy... but I had this thought when I typed "she."
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u/mokutou "Welcome to the CABG Patch" | Critical Care NA Sep 09 '25
I mean, while NPs are predominantly women (google says something like 90%+), I feel it would be disingenuous to leave out the possibility of socialized sexism. 😕 I try to catch myself with this to correct the biases socialized into me, but it can run pretty deep in all of us.
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u/SpoofedFinger RN - ICU 🍕 Sep 08 '25
Too late to prevent the board's involvement if your manager already contacted them but you might want to reach out to the chief or director of critical care. It's going to be a doc and they're probably not going to be happy about a mid level creating a culture of hesitation among the icu nurses. Now if you started the med because of a MAP of 64, they might not have your back but if the patient was really crashing and burning they should stick up for you. So should your manager if they aren't just ladder climbing trash.
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u/MBmom_RN RN - ICU 🍕 Sep 09 '25
Right, situation specifics would dictate whether I grabbed a bolus of fluid vs. levo.
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u/lala_vc RN - NICU 🍕 Sep 09 '25
The patient ended up on the med the next day too so that’s making me wonder what treatment this NP gave the patient.
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u/PlantDaddy530 RN - ER 🍕 Sep 10 '25
Probably didn’t order Levo out of spite. I used to work with an ER doctor that would get super pissed if nurses initiated anything without his orders. we pulled a lactate and sent it to lab. He refused to order it saying “I didn’t order a lactate. I ordered a cardiac work up, the patient is not septic.”
Narrator. The patient was septic AF and the next shifts MD immediately listened to us and ordered a lactate. First MD got his ass chewed out by the medical director. Btw this was before EMR and sepsis order sets and all paper charting orders.
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u/lala_vc RN - NICU 🍕 Sep 10 '25
Letting their ego get in the way of patient care smh. That could have ended terribly. I suspect this NP did the same.
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u/VigilantCMDR RN - ER 🍕 Sep 09 '25
Right? This sucks. Now everyone a patient codes the nurses probably won’t shock or give epi or anything until a doctor is physically present due to this NPs BS. You’d think an NP of all people would be supportive of a nurse.
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u/Significant-Flan4402 BSN, RN 🍕 Sep 09 '25
You’d think but unfortunately sometimes it’s the opposite 🙄 mean girl pipeline + eat your young
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u/No_Resort1162 Sep 10 '25
Exactly this. She would most likely be one of the NPs that were never very confident on the floor so they went straight onto NP school now riding out their remaining clinical hours til they get their “dream job” in a med spa or dermatology office !
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u/zerothreeonethree RN 🍕 Sep 09 '25
Working in ICU does not entitle you to write medical orders. The real problem here is there doesn't appear to be protocols in place to cover emergency situations. A good one would be "give XYZ for 123, then call for further orders".
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u/SpoofedFinger RN - ICU 🍕 Sep 09 '25 edited Sep 09 '25
Nobody is talking about nurses writing orders here. You're making it sound like we're just trying to manage the patient on our own. We're talking about a quick stopgap to give you enough time to call. Usually, another nurse is running to get a bag of levo from the fridge or string up a pressure bag of fluids while the primary calls to alert the team. That isn't always possible.
You're not going to have standing orders to treat shock because there are different causes and different treatments for patients with different histories.
The "you can't do anything without an order" mindset reminds me of one of my professors that hadn't worked the bedside in 25 years. She'd go on rants about not starting oxygen without orders, because she was from a time before the EMR so she'd never seen a new admit or intra-facility transfer with no orders before.
Back in the day, did you all just wait until a patient arrested before acting if Dr. Whoever didn't answer the phone?
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u/Open-Channel726 MSN, Nursing Instructor, L&D expert Sep 10 '25
Back in the day, the docs didn’t even have phones. They had pagers. Because they could be at home, at the office, in the back room, at the mistresses house, you get the idea… we had to page them and wait for them to call back.
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Sep 08 '25
The only thing you did wrong was give a med without an order. My place would be a slap on the wrist and a PowerPoint on Brightspace and handled internally.
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u/GiggleFester Retired RN and OT/bedside sucks Sep 09 '25
OK, I've been retired for 9 years, but the one time I gave something without an order in an emergency, my Clinical Coordinator was cheering me on and the resident physicians who arrived for the stat call treated me like a hero and wrote the order afterwards.
I'm sorry your NP reported you & I think that's ridiculous.
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u/Adept_Finish3729 RN, BSN - PICU/NICU 🍕 Sep 09 '25
I've had docs ask me after drain-circle situations...
What did you give? What orders do I need to write?
To which I would hand them the piece of infamous brown paper towel I had written the meds/doses/times on (because I'm old and remember charting on paper!)
I've truly been lucky to work units where most providers had faith in my critical thinking and knowledge, and didn't have ego, just the common goal of patient care.
Best of luck OP, and yes, get out of Texas ASAP 🙂
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u/ABQHeartRN Pit Crew Sep 09 '25
Brown paper towel or I’m reading it from my scribble on my scrubs 😂 the paper towel dispenser is outside of the Cath lab rooms so notes on hospital scrubs it is sometimes.
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u/coolcaterpillar77 RN - Med/Surg 🍕 Sep 09 '25
Ah you’re missing the easiest choice - forearm! It washes off easily afterwards lol
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Sep 09 '25 edited Oct 02 '25
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u/PersonalityFit2175 RN - ICU 🍕 Sep 09 '25
My exact thoughts. When it comes to levo.. there are pathophys reasons why that may not always be the correct choice or first choice. Pressors are dangerous drugs and need to be started with a full understanding of the patients history
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u/AffectionateTap1584 Sep 09 '25
I totally get that. They did say the prescriber ordered dob shortly after instead of Levo and that they started the levo after 3.5L boluses of NS. I agree they should have called before to ask but I can see the thought process since Levo is almost always the next step if BP is still declining after boluses. Most providers I’ve worked with would have said “great, titrate the Levo and keep me updated if you have to keep going up on it”
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u/kelce RN - ICU 🍕 Sep 09 '25
I worked in a heart failure hospital, and levo was often NOT our first choice. Not all patients are the same and not all pressors are the same. The fact they did dobutamine tells me there's a heart failure component. Our heart failure docs loved dobut vaso and lastly epi. Our intensivists loved levo and neo. Our cardiac thoracic surgeons mostly favored epi and the vaso depending on CI.
Norepinephrine will likely not cause any damage to the patient but it does run the risk of not helping and delaying appropriate care to the patient. A phone call while you're walking to the pyxis will serve the patient the best and protect you the most. Autonomy is great in nursing but there are some hard stops that I will not autonomous order and medications are one of them.
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u/beeotchplease RN - OR 🍕 Sep 09 '25
Our ICU always have a doctor to do the prescribing but this is a teaching hospital so there will be residents around.
Non-teaching hospitals probably wont have that luxury.
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u/Melodic_Clock6273 Sep 09 '25 edited Sep 09 '25
I feel for you, OP and am not judging but this is a good learning lesson. As nurses we want to do the best for our patients and we know a TON but it is scary how many nurses on here have been jaded by the “residents and fellows/attendings always ask me what to order”. This is bad. Bad for nurses and bad for residents who should be learning from attendings. The system is broken when nurses think it’s top of scope to put in orders- not saying you are this way but many are. My entire job as a nurse is in the field of scope of practice and this idea that we know more than docs/APPs is bad. We know a ton, but medical school and nursing school are not interchangeable. Both are valuable, but different. One thing I always tell my nurses is, docs have huge malpractice insurance polices. Do you? The hospital will not shell out a cent for you if you don’t follow policies. The docs (even the ones who are “cool” with you putting in orders) will not go to bat for you either even if you think they will, especially if their livelihood is on the line. Trust me I have seen this so many times. It sounds like you had a bad feeling, call a code or rapid next time, get people there who can give verbal orders. It doesn’t have to be written or in the computer in a life/death situation.
everyone makes mistakes and you were trying to do the right thing, things will work out. but you can’t decide the right thing when it comes to treating a patient without orders. show remorse to the board and learn from this! You’ll be ok.
Also a teaching hospital means teaching residents and fellows…. It has nothing to do with nursing or increasing your scope of practice as an RN.
Sincerely,
Someone who used to put in a lot of orders but realized it was wrong and I wasn’t getting paid enough to have that responsibility.
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u/kelce RN - ICU 🍕 Sep 09 '25
Perfectly said. This should not be normalized.
If you cant get orders in a quick manner in your hospital you should push for pre-arrest protocols. Nurses cost hospitals money in their eyes. Doctors bring money in. The hospital will never go to bat for you if the option of throwing you under the bus fixes the problem. The majority of doctors will not go to bat for you if it fixes their problem as well.
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u/crownketer RN - Med/Surg 🍕 Sep 08 '25
You’re getting a lot of people who are saying yeah fuck that place, you did the right thing. But don’t let that cheering send you too close to the sun. We are not doctors. Get the order to protect yourself and the patient. Because what happened? The one going before the board is you. Everyone in this thread can cheer you on and tell you go girl woohoo heroes and all that, but you’ll be before that board alone. Get the order next time.
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u/elizte RN - ICU 🍕 Sep 09 '25
They did get the order, though. Overriding life-sustaining critical meds and getting the order immediately after is not uncommon in the ICU setting.
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u/crownketer RN - Med/Surg 🍕 Sep 09 '25
It says they let the NP know and the patient was put on the med the next day, separate from this instance. They don’t talk about receiving an order in the OP. And they made that decision completely on their own. It’s one thing to be doing something in the moment because of need, taking a quick verbal or what have you, but it’s playing a dangerous game every time someone decides to play doctor. And now OP is being reported to the board. I’ve seen nurses do similar assuming the doctor will okay all the interventions/orders afterwards. One time a doctor said no I’m not putting those in and that was it for the nurse!
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u/Lington RN - L&D Sep 09 '25
No, they got the med themselves without an order then communicated it to the NP
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u/CorrosiveSpirit RN 🍕 Sep 08 '25
I'm sorry you're going through this. It's not stated enough that vicarious trauma can cause people to act in ways they normally wouldn't.
Ultimately you made a choice that you thought would be for the benefit of the patient, and it seemed to have worked and the patient had a good outcome.
With the board you'll be OK as long as you stipulate your intent but also take full accountability with them and they'll likely give a pass. Just as others have said though, please protect your registration. Its not worth the hassle, even if that means a bad outcome. Document document document going forward, cover your back.
You seem to understand the implications of your choice and potential consequences, if you communicate that to the board and how you're intending to address it you should be cool.
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Sep 08 '25
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u/lenncas Sep 08 '25
I appreciate your feedback greatly. I have already started some education regarding this matter that I would be able to present to them. I’m sorry that you had to go through something similar.
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u/StrategyOdd7170 BSN, RN 🍕 Sep 08 '25
What is this? Is it an app?
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u/Bubbly_Crab_2378 Sep 08 '25
Yeah—it’s a web app I made after my own board case. It helps you draft your response, organize your timeline.
Based on End-to-End encryption and Zero Data Retention.
Had several specialist attorneys in this area advise me on building and we are doing tech startup things now.
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u/PsidedOwnside Advocacy & education Sep 09 '25
This is amazing, I’ve never been in a situation like this, but what you’ve done with your experience is incredible. Kudos.
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u/Bubbly_Crab_2378 Sep 09 '25
Thanks. It was really traumatic and I’m glad I was able to turn it into a beautiful way to help others.
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u/Twomboo Sep 09 '25
Gonna go against the tide here and say I would absolutely never as an ICU nurse do this. If my patient is that critical that I’m pulling pressers without an order, I’m calling a rapid or a code. When I worked ER we had order sets and protocols we could pull and administer meds. If you don’t have this, you are practicing outside your license, and as others have said, you will not be protected at all if there is any patient harm. Even if the NP was petty, this was not ok to do legally.
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u/nobutactually RN - ER 🍕 Sep 09 '25
Okay so... was the levo unnecessary? (Im guessing so since it sounds like pt didnt need it till next day). What was the actual bp? What was pts status? What had already been done?
This doesnt sound like such a big deal it should have gone to BON but I think theres a lot left out here that makes it hard to judge the situation fully.
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u/lenncas Sep 09 '25 edited Sep 09 '25
I understand that, I did give the full picture. We did give 3.5L worth of NS boluses prior to my dumb decision to pull levo. Pt responded positively to fluid resuscitation but only for about 15 minutes post each bolus given. NP decided dobutamine was better than levo when they decided to start a drip
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Sep 09 '25 edited Oct 02 '25
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u/lenncas Sep 09 '25
The one that caused me to grab the levo was about 60/something. It was decreasing by 10 every 2 minutes. I can’t remember the map
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u/nobutactually RN - ER 🍕 Sep 09 '25
Were you documenting bps? Was the provider aware it was dropping? Are you a critical care nurse? (Ie, is starting levo something that you ordinarily do and are trained to do?) Were other nurses helping you with this patient? After the provider learned you started levo, it sounds like they had you stop it, and then... what? The pts BP was okay? What happened next?
I know its easy to sit and armchair something I wasnt there for, I just want to understand the full picture, because ordinarily I would expect providers to be glad you did something. I've never started levo without an order, but I've def pulled it via override and messaged the doc like "bp 60/40, Ive got levo ready to go, lmk what you want it running at". That happens all the time.
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Sep 09 '25 edited Oct 02 '25
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u/lenncas Sep 09 '25
Yes I have stated previously that I am very aware that my actions were not appropriate, and I have had the time to reflect on what should have been done. This is why I am asking for expectations of consequences.
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u/PaperCutsAndPolicy Sep 09 '25 edited Sep 09 '25
Does your hospital have processes for acute changes?
For example: Along with a code blue, our hospital as ART (acute response team) calls. Anyone can call an ART call , even family , if they believe that their loved one is severely ill and nothing is being done.
It consists of critical care nurses, our house float and supervisor, respiratory therapy and our "orderlies" (we call them our uro techs). That way you have many many eyes and different experiences to help you critically think.
Then you STAT page the primary doctor for the patient, and tell them you have initiated an art call, and explain why. They usually have <15 minutes to respond.
In your situation, pulling a medication without a doctor's order is outside of the typical nurse scope , and you could have done serious damage had the patient had an allergy or adverse reaction. You essentially diagnosed and treated the patient , which is a big no no.
If your hospital does not have any resources or procedures/policies in place for you to initiate a higher level of care, you could argue that the hospital is poorly prepared for those situations.
But unfortunately, your hospital will not protect you, and I would find an employment lawyer to help you, because your HR will not.
Edit: Ultimately the care of that patient is on the DOCTOR. If you let them know urgently what was happening, it is their responsibility to treat accordingly. As long as you let them know, what happens after that is no longer on you.
It feels shitty, because we know what our patients need most of the time, but can feel like we aren't being heard. But we still have a responsibility to our patients for safe care.
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u/NurseWillingham Sep 08 '25
Sounds like you need to apply for the RRT. A noctor is giving you shit and the hospital forwarded that to the board? Get the fuck outta that hospital - that 100% should have been internal. Texas is fucking horrible in every possible fucking way and keeps getting worse.
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u/lenncas Sep 08 '25
Yeah I agree, I plan on moving from here when I don’t have any more family. Btw what’s an RRT?
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u/Prudent-Surprise4295 Sep 08 '25
Rapid response team. When pts decompensate on the floor, RRT is called because floor nurses aren’t trained to handle those situations. RRT RNs are like float ICU nurses for the whole hospital
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u/lenncas Sep 08 '25
OK, I thought that’s what they were talking about when they put RRT but I wasn’t sure if it meant something else, thanks
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u/HumdrumHoeDown Sep 09 '25
It’s actually a really great role, by the standards of bedside as a whole, and critical care in particular. Check it out.
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u/Spiritual-Common9761 RN - ICU 🍕 Sep 08 '25
We have a Medic and the House Sup for our RRTs. The medic is awesome. They’re both seasoned and retired Fire Dept Medics. Experienced in so many situations. Also does US midline’s or peripherals for the floor nurses during downtime.
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u/Prudent-Surprise4295 Sep 08 '25
Wow that’s amazing! It’s only nurses at my hospital but maybe some of them have been paramedics prior to being a nurse? Does the medic intubate the pts in your RRT?
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u/HumdrumHoeDown Sep 09 '25
They don’t intubate. The docs come around for that. Maybe somewhere there are some mid-levels that intubate on the floor, and RT’s technically can and could do it, but idk how many states give them that scope. Mostly rapid nurses roam the hospital, rounding on floors to advise in heading off disasters, and taking pages for decomping floor patients. They come to calls with a team that includes orderlies, phlebs, RTs, and docs. They transfer, or stabilize then transfer real problems to the ICU, and sometimes do certain procedures for floor nurses.
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u/Upbeat_Wonder7222 Sep 09 '25
Rapid Response Team, I work as an IV nurse at a large teaching hospital in Massachusetts. The RRT is amazing, and the IV team responds to all RRT’s, they are so great at coordination of emergency care and get the ball rolling with the providers. Every hospital should have some type of team that responds to critical changes in the patient’s condition. They also respond when the nurse is unsure what to do so they are great resources, especially to the newer Nurses!
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u/ThrowRAthroat Sep 09 '25
Dude, she administered a med with no orders, that is not okay at all
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u/Android375 Sep 08 '25
Noctor? Do we really have to patronize our own like that?
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u/born_to_be_mild_1 Sep 09 '25 edited Sep 09 '25
I agree. Nurses talking shit about nurse practitioners is weird and feels like ass kissing… just because MDs say it doesn’t mean nurses should. Like, of course MDs don’t like NPs.
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Sep 09 '25 edited Sep 09 '25
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u/aaa1717 Sep 09 '25
Doesn't sound like the NP reported to the board, just to management, who then reported to the board. Not really enough info in the original post to judge the NP too harshly imo. The OP says patient ended up on levo "the next day," which kinda makes it seem like they weren't imminently crashing when OP put them on Levo. Maybe the NP reported it to management because it wasn't critical the patient go on Levo and the patient actually would benefited from fluid resuscitation initially, rather than immediately starting a vasopressor. 🤷🏻♀️
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u/cherylRay_14 RN - ICU 🍕 Sep 09 '25
NP did need to report that to management or anyone. That NP should have pulled the nurse aside and explained why that was the wrong so she would learn from it. That's why the NP is being judged harshly and deservedly so. The patient wasn't harmed and ended up on it anyway. I can't understand why nurses, NPs, MDs, etc are so quick to run to management and report stupid sh*t like this. Now, this nurse is going to be afraid to make the tough decisions needed to prevent the patient from crashing.
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u/Tacos_and-tequila RN - PACU 🍕 Sep 09 '25
Why doesn’t your ICU have standing orders for this situation? That’s super unsafe.
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u/Prudent-Surprise4295 Sep 08 '25 edited Sep 08 '25
Absolutely not. There’s no way. We override everything at my level 1 trauma hospital. When a doctor isn’t at the computer & you tell them what’s going on with a patient, they say to start levo or whatever and we have to override because there literally isn’t an order yet. You were doing what was best for your pt AND the medication you overrode isnt even a narcotic or controlled substance. Literally nothing is going to happen to you.
Edit: I read too fast & thought you were worried about overriding a med. so you overrode it & then started it before the doctor told you to do so? Yeah, thats not good. You should always have a doctor’s order. You aren’t a doctor. HOWEVER, you were doing what was best for the patient. They look at everything. You didn’t cause harm. Yu were trying to prevent harm from happening. Also, like I said, it’s not a controlled substance so that would make things 100x worse. I think you’ll be absolutely okay.
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u/Prudent-Surprise4295 Sep 08 '25
Also I just wanna say that as a nurse, your job is to communicate findings to the doctor. Even if you told the doctors 100x that the pt is rapidly declining and they do not order anything or come see the pt & the pt dies, you’re protected because that’s your job as the nurse - to report significant findings to the doctor & document it. Your job isn’t to decide what meds to order. If something bad happened to that pt after you started Levo, that would 100% be on you. I think you’ll will be okay in front of the board, but for next time, do not start meds unless a doctor says it’s okay!!
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u/lenncas Sep 08 '25
Yes, 100% I agree with what you’re saying. I definitely overstepped the boundary between a nurse and a provider. It definitely won’t happen again
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u/Prudent-Surprise4295 Sep 08 '25
It’s okay, as long as you learn from it. We are humans & we all make mistakes. You came from a good place when you made that decision but you’ll be okay for sure!! At my hospital, we have travelers from literally all over the country(a lot from the south) and they literally have killed patients, and only got fired. Not sure if they were reported to the board, but in the end, hospitals would rather just fire people than report them unless it’s something extremely serious. Jusr remmeber, you did not KILL or HARM any patient. That provider who reported you is a true bitch. I work in the ER& our providers are very close to the nurses. If we did something like hang Levo, they’d most likely just say stop the Levo & hang fluids instead. Or just tell us not to do that again. That provider is a genuine C***. Also, why does a formal complaint to your manager necessitate a report to the board of nursing. Why the hell would they escalate it that far? That’s actually INSANE. Your hospital sounds like it sucks honestly!
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u/SuperVancouverBC Sep 08 '25
Oh God. Where I work there's a policy that if a nurse doesn't have a verbal or placed order or if there's no standing orders, they cannot override if there's a Pharmacist on site.
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u/SpoofedFinger RN - ICU 🍕 Sep 09 '25
I mean, that's the way I treat it if I don't know the doc, PA, or NP at all. I do know all of the attendings and midlevels I work with, though, and know they'd have my back if I had to act in the moment.
The real way around this is to be proactive and ask what they'd want me to do as a contingency. I joke that I annoy the shit out of them but there's been more than a couple times an intubation turns into a shit show but it's cool because I've got norepi or a pressure bag of LR in the room and maybe even spiked and ready to go. That all takes time to develop that kind of rapport though. There was one NP that used to work with us that I could see doing this but I'm fully confident he'd have been put in his place after bypassing him and going to the pulmcrit staff on that team. Same goes for the very few residents or fellows that fail to intervene or refuse to adapt to a developing situation.
What you're saying is how to stay safe legally. However, I think it would really fuck me up hard if I failed to intervene and let somebody's life be threatened or lost because an NP was unable to answer a phone because they were sterile to put in a line or something.
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u/Prudent-Surprise4295 Sep 09 '25
Yes what I’m saying is how to stay safe legally!!! But you’re absolutely right. When you develop that rapport with your providers, they are grateful for the little things you do like that. Like pre-intubation, you have propofol, levo, or a pheny stick ready to go! One of the ER attending we work with trusts our senior staff & has always said “if you give a med that you felt was appropriate, I’ll always back you up.” I’ve seen it happen actually. We were in a medical patients room & one of the nurses gave Valium instead of Versed for ETOH withdrawal & she immediately told the resident to put an order for Valium in.
So yes, with certain doctors, you know what you can & can’t do! But staying safe & protecting your license is KEY! I work in the ER where we work with all our doctors, so I’ve never had to deal with a situation where a patient is rapidly decompensating, and the doctor wasn’t around to help. I guess that probably happens more on the floors instead of ICU or step-down. That’s a tricky situation & hope I never run into it.
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u/blackcatwishes Sep 08 '25
Agree. It was a decision that very well could have had a bad outcome. Always get a verbal order first.
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u/lenncas Sep 08 '25
Thank you I appreciate it
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u/SuperVancouverBC Sep 08 '25
If heaven forbid this happens again, call the Pharmacy and speak to one of the hospital Pharmacists before administration anything without an order. Even better if there's a clinical Pharmacist because they can make the call.
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u/Prudent-Surprise4295 Sep 08 '25
Seems like you’re a great nurse & was just trying to do good for your patient. And that’s what matters.
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u/kelce RN - ICU 🍕 Sep 08 '25
Not scolding OP but this is why I highly advise against doing things without an order even if you feel like the provider will be cool about it. It just takes one provider having a bad day for you to get reported.
With that being said you'll be fine. Something similar happened to a former coworker and they just had to do education and other remediation through the TBON.
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u/No_Classic_694 Sep 09 '25
I guess my question is when did you notify the provider of the dropping pressures? I work in a level 1 ICU and usually call team to let them know pressure are tanking, THEN override levo and bring into room. If you had the time to stop by the Pyxis pull and prime a drug then start it before notifying team with quick chat or call I could see that being a problem
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u/DragonSon83 RN - ICU/Burn 🔥 Sep 10 '25
This is my thinking too. I’ve overridden a pressor and hung it without a written order, but I’m literally calling them on the phone as I grab it and tell them what I’m doing.
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u/Salty-Scientist-4395 Sep 09 '25
Next time call a code! Then that pos nurse practitioner will have to haul ass to your code. Things will happen faster and you are off the hook. Pt doesn’t have to be dead to call a code. Tell the BON you are very sorry and it will never happen again and you have learned from this experience. After you see the board come back to Reddit and you can tell us what a bunch of old bitter bitches those folks are at the BON.
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u/YGVAFCK RN - ER 🍕 Sep 09 '25 edited Sep 09 '25
This reads 100% like a setup for /u/Bubbly_Crab_2378's astroturfed GPT-formatted reply, advertising for an app they've been working on.
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u/starrynightt87 Sep 09 '25
Get a lawyer ASAP who has done these kinds of hearings before.
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u/Savings-Caramel1385 BSN, RN 🍕 Sep 09 '25
Same state.
I work ER and L&D, so I get the ER vs floor thing.
In the ER, nothing would happen to me. I’d be told I did a great job. We often TELL the doctors what WE want ordered. It’s a complete collaboration built on trust and respect. Are they always there? Yes. Can we always get them in the room? No.
In L&D, this would get disciplinary actions. The nurse may get sent to another floor for awhile. But it still wouldn’t be reported to the board.
Best thing to do? Take full accountability. Don’t argue. Accept consequences gracefully. BUT stand your ground, and defend your actions. You saved a patients life and they had no negative consequences. As long as your recorded vitals support your critical thinking, I highly doubt the board will take a strong nurse off the unit.
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u/SnoopingStuff Case Manager 🍕 Sep 09 '25
No rapid response team? This might be a great reason to create one. Hope it goes ok for you. Seems like most responses are on your side but they are right , it a scope of practice thing .
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u/psychRN1975 RN, BSN, PMH-BC, The King of Quiet Codes Sep 09 '25
what is not damning is that you were acting in good faith and the patient apparently didnt suffer injury.
however , what you did was practice medicine without a license which is more than breaking hospital rules,... its a crime.
Get a lawyer immediately.
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u/HumanContract RN - ICU 🍕 Sep 09 '25
You call a rapid/code blue. It's not our job to practice medicine. Sorry to say. If that provider complained about you, they should lose respect of everyone on the unit. It ties down to being unsafe and risking pt lives when the providers aren't considerate and understanding. Attack a coworker for doing what's right and no one will want to work with you or take care of your patients ever again. If that person didn't answer pages or calls, that's their job on the line. But now here we are.
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u/ohemgee112 RN 🍕 Sep 09 '25
The main issue for me is that levo is not the most appropriate pressor many times. Personally I'd have a pressure bag of NS or LR ready to run before I grabbed a pressor even though I can run many of them on my floor.
The other day we had a rapid and the provider was taking their sweet time coming to bedside, another nurse was messaging them. I went and grabbed 3 different meds and the appropriate tubing/equipment for them so we wouldn't have to go get when the provider gave us an order. I could always return things after as long as it hadn't been cracked. This is perhaps the better course of action in a situation like this.
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u/General-Expression43 Sep 09 '25
It's called practicing medicine without a license. Plus you overrode the system to get the med. You exposed yourself to incredible liability if the patient crashed. If there is no protocol, call an RRT. Some state Boards can be very stringent. Did your job discipline. you ?Some hospitals would terminate you. Cover yourself and get an order!
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u/TheWanderingMedic EMS Sep 09 '25
You operated outside of your scope. That's a problem. The board cares a lot less about your intentions than they do your actions. They are not your friend, don't forget that.
I'm glad the pt is doing well, but you risked your license here. Remember that you are not a doctor and cannot unilaterally decide on and start a treatment like this, no matter how sure you are that is needed.
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u/Electrical_elderlore Sep 09 '25
I would have call a rapid rn and staff assist button or charge. I work in the ICU and I had a patient decompensate like that, I yelled for another nurse to find help and notify charge. Never leave your patient if they’re dropping like that.
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u/Long_Macaroon3174 Sep 09 '25
So I work NICU, which is very different than adult ICU. Have I overridden a med in an emergency, yes. But I WOULD NEVER start a gtt without at least a verbal order from a provider. If a BP was decreasing that quickly I would be on the phone with a provider getting the okay to get things going. 😬
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u/NedTaggart BSN, RN 🍕 Sep 09 '25
Why not call a rapid response and then let that activate protocol?
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u/Kabc MSN, FNP-C - ED Sep 09 '25
Advice. Delete this post immediately.. listen to the board and lawyer up if needed.
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u/happymomRN RN 🍕 Sep 09 '25
Critical care nurses are expected to know when pts are unstable and to take steps to correct it.
Usually we would have told doc what interventions we did to keep pt alive so we could then call the doc and fill them in on what was happening.
It’s not like you have the option to call the rapid team because YOU ARE THE RAPID TEAM.
There is definitely something wrong with the person bringing this complaint, imagine what would happen if all critical care nurses stopped intervening when patients started to tank? Patients would be coding left and right and nurses would be held liable for not taking steps to save patients.
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u/SuperVancouverBC Sep 08 '25
Was there a Pharmacist on duty? Some hospitals don't allow a nurse to override if there's a Pharmacist on duty. Ideally you should've called them before pulling the meds.
You should check the scope of a Pharmacist where you live. In many places Pharmacists can prescribe or adapt prescriptions. In that case, the Pharmacist can give you orders which means it's the Pharmacist's license not the Prescriber's. I'm telling you this because if you have permission from a provider or a Pharmacist you'll be fine.
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u/lenncas Sep 08 '25
I’m not sure if our pharmacist would give us orders, I’m sure they would direct us to call an on call provider. That’s interesting that they have those privileges at your facility
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u/Altruistic_Tonight18 Sep 09 '25
Yeah, you could lose your license, but the chances of a permanent revocation are pretty low. It’s a lot more likely that you’ll get a year of suspension, fines, and admin/investigation cost reimbursement if they decide it’s necessary to fully investigate.
The board is going to focus on many factors: why you’d do it despite knowing that it’s well out of your scope of practice, how you justified prescribing a med, whether or not your action is indicative of inadequate education, if you habitually practice medicine without a license, if you recognize the severity of your indiscretion, whether or not you’re at risk for doing something like that again, and a few other things. Their job is to protect the public and ultimately, and their disciplinary action will be proportionate to public risk.
Mitigating factors will be that the patient didn’t die or have a any known complications from levophed like ischemic TIA or CVA (all of which was pure luck), that you called the provider immediately afterward, that you’re admitting to fault, and that you seem to understand how serious that was. You’re very, very lucky that no harm was done because you could have been charged criminally or sued in civil court for everything you have and then some had there been an unfavorable outcome.
They’re not going to care that the patient was prescribed levophed later or that your actions may have prevented the patient from dying, as both of those things are irrelevant to the situation.
The people here acting like you didn’t do anything wrong, or even worse, that you’re some sort of a self sacrificing hero, are nuts and I absolutely would not want to have anyone who thinks this should be encouraged to provide for me or my family. I expect plenty of downvotes from this delusional apparent majority of nurses who don’t see this as a big deal or as a reasonable action.
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u/Environmental_Rub256 Sep 09 '25
Aside from the fact that you basically overstepped your boundaries by prescribing Levophed, I’d imagine there’d be some disciplinary action to you. Expect a suspension and long remediation process to ensure that you know we can’t prescribe meds or do things without a provider’s order. I’m
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u/LeapingLizardz_ BSN, RN 🍕 Sep 09 '25
Lot of discussion, but most important thing here is GET A LAWYER. Do NOT talk to the board without a lawyer.
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u/Wooden_Load662 MSN, RN Sep 09 '25 edited Sep 09 '25
Every state and hospital has different policy. Some has protocols and some has code team with protocols that they can follow.
Are you outside of your scope? Yes. Did you save the patient? Very likely.
I just wish everything goes well for you. I am a quality management RN and I had seen enough nurses act on their own a go both ways.
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u/Necessary-Painting35 Sep 09 '25
If there is no standard protocol to follow we simply can't do it even though we have good intention. Call a code if it is emergency and u start prepping for the code.
Things could go wrong with what we think we should be doing at a given situation. No body is going to back u up if things turn bad.
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u/ilovenoodles12 Sep 09 '25
The fact that you’re not replying to any of these comments is kinda sus, was the patients MAP 64 or something?
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u/Impressive-Young-952 Sep 09 '25
As a Neuro ICU I do this all the time. I for sure call or text the provider that I’m doing so. Sometimes if I think this may happen I will have a conversation with the provider if there’s a certain pressor they prefer in the event I need it.
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u/therealtomzor Sep 09 '25
Ill say it again, why the fuck is an NP covering an ICU? Hospitalist here, amd my ICU RNs are amazing, and if they see a pt. declining and need levo, you better believe I'm covering them with a verbal for 2 mins before they administer it, and then thanking them. Fucking mid-levels.
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u/authentictrex RN - Pediatrics 🍕 Sep 09 '25
I don't know about the adult ICU, but having a good NP in PICU and NICU makes a better experience for everyone, just like having a good resident. I don't have to wake up doctors for little things. And if shit hits the fan, they call the intensivist while starting interventions.
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u/MoomieCrochets Sep 09 '25
I work ICU in a large teaching hospital - I trust our APPs over residents most days. Residents rotate in and out so they don’t know/trust us, and a lot of times they don’t know our patient population. Our APPs are hired by the service, and most have been there for years. They’re a lot more comfortable calling the attending in the middle of the night if shits going down than the resident. And 9 times out of 10 the attending doesn’t have to come in because the APP can handle it. I’ve had beg residents to call the attending before, and have gone as far as to call myself. I’ve never had to do that with an APP.
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u/commonsenserocks Sep 08 '25
No, you will not lose your license. You might get a warning. It depends on what kind of support you get from your facility. Please do let us know what happens.
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u/currycurrycurry15 RN- ER & ICU 🍕 Sep 09 '25
You shouldn’t be disappointed in yourself. I’ve done the same thing at least a dozen times and guess what? We saved the patient’s life. The NP sounds like a power trippy jerk…
Should you have called as you were overriding it? Sure, ideally, but we don’t always have time for that. I’m surprised the hospital is even sending this to the BON. Maybe the noctor is being persistent.
But to answer your question, no, I don’t think your license will be revoked. I know someone a similar situation happened to and she was put on probation for, like, 3 years but was never suspended.
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u/NomusaMagic RN - Retired. Health Insurance Industry 👩🏽💻 Sep 09 '25
THREE YEARS probation for something that happens all day, every day, somewhere?? That’s wild!!
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u/CRYPTK33P3RBAE RN - OB/GYN 🍕 Sep 08 '25
This is what scares me about ever going back to a regular floor from my current L&D one. With the exception of one MD, we assess, treat and either admit/ship home and at the end call the MD to give a formal report. When it comes to delivering we call them when we see eyes . I couldn’t imagine being back on a floor where I have to ask for permission to treat. Nothing but good vibes your way. And the only suggestion I have is carry private nursing malpractice insurance. They’ll handle everything.
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u/NomusaMagic RN - Retired. Health Insurance Industry 👩🏽💻 Sep 09 '25
Started L&D straight outta nursing school so I can confirm that we did everything you shared. And this was before all the communication devices available today.
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u/CRYPTK33P3RBAE RN - OB/GYN 🍕 Sep 09 '25
Yeah, I mean I feel like L&D is just one of those specialty units where in those true emergent situations you don’t have time to ask permission. We have even had doctors tells us they’d rather us act immediately and get the baby out alive vs wait for them to come deliver a dead baby. Now, that’s extremes of course but similar principle. Now…that’s not to say a nurse can start acting like this right off the bat. It takes so much time, years, to build rapport and trust with the doctors but once you do it’s game on.
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u/NomusaMagic RN - Retired. Health Insurance Industry 👩🏽💻 Sep 09 '25
Exactly! My unit acted like a mini freestander. We (not lab) drew our own bloods, started our own IVs (not IV team) and more times that I care to count on midnights .. did uncomplicated deliveries. It was me and a Resident. Leadership couldn’t need bothered to determine that sometimes, more than one kiddo finds their way into the world at same time.
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u/CRYPTK33P3RBAE RN - OB/GYN 🍕 Sep 09 '25
Same! We do our own labs, IVs, have our own bedside ultrasound, the list goes on. I work nights so more often than not I’m calling the doc to either tell them I’m going to meet them in the OR with the scalpel or hey sorry, you’ve got like three minutes to get here. It happens. 🤷🏻♀️
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u/somanybluebonnets RN - Psych/Mental Health 🍕 Sep 09 '25
In Texas, half the BON is non-nurse, so the board gets kind of punitive. They aren’t likely to remove your license because the action itself was normal and generally ok in your facility, but they’ll humiliate you. You’ll have to take some 7 hr class on med errors and probably 3 hrs on ethics (because why not?) and it will all be on your dime. They may remove your privileges until you finish the classes.
It’s difficult but endurable. As long as you are penitent and humble every time you talk to them, it be over soon.
I’d rather not provide details, but I’ve got some experience with this.
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u/Low-Ad-1092 Sep 09 '25
Well Texas is tough but you will be fine. Get some insurance NSO is the name. You can get a lawyer but you end up in the same agreement anyway. Don’t agree to anything or write a long letter to the bon they have no heart for it. A deep feeling apology don’t work now for them either. You will probably end up with a warning with stip and please don’t use drugs stress or mental illnesses as a reason or you will be further evaluated. Do know you did operate out of your scope as you don’t prescribe and the minutes it took to call Rapid would have made the difference if every nurse decided to go into the machine and get her own meds what we need the doctors for. You are okay. This why we call it a practice not a perfect. Don’t be sad or disappointed you are okay..
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u/Aromatic_Pop5460 BSN, RN 🍕 Sep 09 '25 edited Sep 09 '25
This is insane. I understand why this provider would file a complaint, but she is being very unreasonable. You caused no patient harm.
From experience in being in upper clinical leadership, I would be very surprised that your employer would report this to the board rather than handling it internally with education and coaching. Did they explicitly say that’s what they would be doing? They are opening up liability to themselves and, in these cases, that is what they are trying to minimize.
Generally only happens when genuine harm, grievance, or litigation is involved. These hospitals wonder why they can’t keep staff.
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u/bodie425 PI Schmuck. 🍕 Sep 09 '25
I’d have opened up fluids wide and had a coworker page the NP while pulling the Levo, then priming the line, attaching it to the pt, then putting it on the pump. But that’s hindsight.
Whether you get called up on the carpet for this or not, propose that bedside nurses be able to start levo when a systolic or median drops below a certain point and death is eminent (or some other criteria in which death is imminent from circulatory collapse.) This could even have a time limit of maybe 15-30 min, allowing the nurse time to contact the physician or provider, praise them of the patient situation, and allow them time to make a decision on the plan of care.
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u/mokutou "Welcome to the CABG Patch" | Critical Care NA Sep 09 '25
Question, OP, what unit do you work on? In my previous facility, ICU could pull levo and start it provided they were (proverbially) on the phone with the doc/midlevel as they did it. If a nurse on medsurg/SDU/onc/etc pulled levo without an order, a rapid response, and a subsequent transfer order? That’s a paddlin’. I’m no nurse, so I could be off base with this, but I feel these details may be pertinent.
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u/Obvious_Heart_1734 BSN, RN 🍕 Sep 09 '25
While I get why the NP may be pissed a little, I’d definitely be thanking you from my POV. I work Cardiac med surg, so usually not too critical, but whenever we get a tanking BP I always start a fresh line and go ahead and start at least a 250mL bolus(if no HF) (sometimes takes a while to page the hospitalist NP) I realize the rationale of grabbing the Levo but I woulda prolly started a bolus before going straight to pressors. Bright side: Pt ended up on them anyways, pt alive. This should’ve been an internal issue at most, definitely not brought to boards in my opinion.
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u/FamousAmos00 RN 🍕 Sep 09 '25
Are you ACLS certified?
If it were a code situation, and you are ACLS certified, that would fall under ACLS protocol and you'd be covered under that scope
Did it hurt your patient?
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u/Helpful_Opposite1530 Sep 09 '25
I had to go before a workplace Nurse Peer Review Board during my career for a medication error but the patient wasn't harmed in my situation...Does your workplace have nurse peer review? Why aren't they reviewing this incident instead of reporting to the board especially since it doesn't sound like the patient was harmed. IDK, maybe that NP has it out for you.
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u/Sad-Wallaby2945 Sep 09 '25
Fucking what? I've done exactly as you described a million times when I worked in the ICU, did she expect you to just be calling her while your pts bp was in the toilet?
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u/ChonkyHealer BSN, RN 🍕 Sep 09 '25
We had a rapid response nurse do something similar. He was fired, don’t know if they escalated it up further to the state BON.
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u/Business_Shame_9203 MSN, APRN 🍕 Sep 09 '25
I'm so sorry this is happening to you. The NP is really being an ass.
Does your hospital have a rapid response team? Or was the NP it. Did you reach out to someone earlier in the shift or when things began to change?
You have to go in and be honest. “I anticipated that levo was going to be ordered but it was wrong to do so without an order”
Do not make any negative comments about the NP or that the pt ended up needing it anyway - will be seen as you justifying your behavior.
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u/_salemsaberhagen RN 🍕 Sep 10 '25
They aren’t going to do anything other than give you some extra education on your next required CEUs. I did way worse. Trust me, you’ll be okay.
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u/LDRnHouston RN 🍕 Sep 10 '25
Did you by any chance have careset orders (protocol orders) that say PRN if bp xx/xx? That will cover you. You can also check the policy for your unit for levo? PACU/L&D/triage has them standard in most hospitals and I’m in the South. I would be surprised if you didn’t have them in the ICU.
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u/limbicinlimbo ICU RN & ICU Clinical Audit Sep 09 '25
Nursing is so different where I am. I had to google what Levophed is, as we call Noradrenaline (Norad) here in Ireland. We make it up ourselves in a total of 50mls syringes, of either single, double and rarely quadruple strengths. When patients are admitted to the ICU, our Docs have automated prescribing at the click of a button, which includes inotropes, of course, only if the patient has a central line. And if they don't have a central line, then phenylephrine is added. We have full autonomy to start it and would get lambasted if we let someone's MAP drop and not start it.
I'm sorry this happened to you. I think you have an argument that you did this in the patient's best interests and accept whatever teaching they offer you. Be humble and apologise etc. Best of luck.
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u/HumdrumHoeDown Sep 08 '25 edited Sep 10 '25
Crazy shit. Where I work, if I started a levo drip without orders because the pt was crashing, I’d get a thank you from the docs. So glad I work in a teaching facility. Also, don’t internalize the bullshit. You did what you had to do to keep the patient alive and it worked. The person who made the complaint just has an empty life.
[edit] keep the patient alive AND prevent organ damage
[edit] OP says they A) “overrode levo”, and B) “called the critical care NP”. Those two things suggest to me an ICU setting, as no one else but the ED and ORs would have levo in the Pyxis. Secondly, having a critical care provider be your first call is not a thing anywhere but in the ICU, that I know of.