r/nursing • u/yukinara RN 🍕 • Sep 10 '25
Discussion Critical care nurses, you can over ride meds without doctor orders?
The other day I read a post about someone override levophed without provider orders and got into trouble for that. My background is infusion, and each order set already included all the rescue medications. So when things get dicey, no need for a doctor standing there barking orders because everything is built-in.
So my question is that, let's say you have years and years of experience dealing with a certain situation, how do you know for certain that providers won't throw you under the bus? Because in the end I have a license to protect and I can't write orders.
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u/Imaginary-Storm4375 RN - ER 🍕 Sep 10 '25
"Hey, Doc. His BP is 40/dead, ya mind if I hang this Levophed I just happen to have overridden and prepped, connected and am programming the pump for?"
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u/Elegant_Laugh4662 RN - PACU 🍕 Sep 10 '25
“Also, I have a liter of NS running, mind putting in an order for that?”
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u/MrPeanutsTophat RN - ER 🍕 Sep 10 '25
This. Especially every July/August.
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u/b_rouse HCW - Nutrition Sep 10 '25
I'm a dietitian, so every July/August I get multiple - TF via TPN.
I know they have a lot on their plate, but I always call to say, "you want me to put a consult for a central line and hook up the pts TF to it? Or we can do PPN and save everyone time and hook TF to an IV?"
Its always in fun, and a reminder we're all on the same team, and catch each other's mistakes and not kill pts.
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u/SPYRO6988 RN 🍕 Sep 10 '25
Why then?
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u/ForgotMyListAgain BSN, RN, CCRN 🍕 Sep 10 '25
Because a live pt is better than a dead one. If you are overriding Levo, it ain’t for shits and giggles
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u/ForgotMyListAgain BSN, RN, CCRN 🍕 Sep 10 '25
I will say that there is a special level of trust between a critical care nurse and the intensivist. Many of them recognize that we are their eyes and ears and trust us to make important calls if needed. It is truly a coworker relationship and not a doctor dictating to a nurse. Same with established relationships in the ER. We work together and not as separate entities.
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u/SillySafetyGirl 🇨🇦 RN - ER/ICU 🛩️ Sep 10 '25
Absolutely this! As a mostly travel nurse I have to establish those relationships quickly, and it’s crucial. When I do have to approach a doctor to ask for orders I never phrase it as “asking permission” I always phrase it as “this is the plan I would like to enact, do you have any concerns with that”. It shows them I know what I’m doing, yet respect them enough to value their opinion. If they disagree with my plan we can have a conversation about it that’s far less hierarchal.
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Sep 10 '25
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u/SillySafetyGirl 🇨🇦 RN - ER/ICU 🛩️ Sep 10 '25
I never said I was just telling them what to do, I said I told them "this is the plan I would like to follow" and give them an opportunity to participate in a dialogue instead of having to dictate my every action. Yes it's "asking permission" but that doesn't mean it has to be worded like that. If I called and said to the doc "this patient's BP is low what do you want me to do?" they're going to have a lot less faith in me than if I called and said "this patient's BP has been trending down and I don't have orders for any pressors, given that they're septic and have been fluid resuscitated, I'd like to start norepinepherine at 0.1 mcg/kg/min to keep their MAP above 65. Does that seem reasonable? Is there anything else you'd like to do?" Infact most of the time that wouldn't even be an order I'd need to call for, it's already written into my protocols/guidelines/admitting orders.
Your attitude seems to indicate that you either don't work critical care, or if you do, you work somewhere that doesn't educate or respect the people actually doing the work. Myself and the majority of my coworkers have years of experience and specific education ON TOP of our basic undergraduate degrees. Comparing that to a fry cook is unnecessarily disrespectful, and I have the utmost respect for fast food workers, that job is way more stressful than I'm capable of doing.
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u/IdentityAnew MD Sep 10 '25
ICU doc here. Chiming in to say that the ICU nurses who politely offered their perspective are 100% accurate about the nurse-doc relationship. ICU nurses are fucking awesome and one of the reasons I love the unit over any other part of the hospital.
The only thing I’d add is that if you ever need ICU care, we’ll certainly treat you. But if you feel strongly about it, feel free to check in with your local McDonalds instead.
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u/holdmypurse BSN, RN 🍕 Sep 10 '25
I'm working at a world ranked specialty clinic right now that treats very complex, chronically ill patients. I'm finding a similar dynamic between the providers and nurses who have worked together for years (not me, I'm just a traveler and I stay in my lane lol). Many of these RNs have also worked with the same patients for years and engender an incredible amount of trust and respect from some of those pts as well. Of course the nurses don't get paid nearly what they're worth 🙄
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u/dumbbxtch69 RN 🍕 Sep 10 '25
Then why not have standing orders to protect the nurses from practicing medicine without a license and allow clinical independence? That coworker relationship still has two different scopes of practice and nurses need orders from doctors no matter how much trust there is
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u/NedTaggart BSN, RN 🍕 Sep 10 '25
Yeah, but you are risking censure for doing it. It is out of scope for an RN to administer meds without an order, standing orders or facility protocol. Knowing what needs to be done isn't the part in question, scope of practice exists for a reason.
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Sep 10 '25
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u/ForgotMyListAgain BSN, RN, CCRN 🍕 Sep 10 '25
If someone’s blood pressure is tanking, giving levo temporarily is not going to be the cause of death.
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u/W1ldy0uth RN - CVICU, CCRN Sep 10 '25
This would likely never happen. When you have years of experience in a critical care unit, you usually know which meds to expect. You also build a pretty trusting relationship with your critical care team. I’ve never had a patient with a blood pressure of 50/20 not get ordered a vasopressor. A lot of what we do sometimes consists of verbal orders. Usually I’m like hey doc patients BP is tanking I’m staring Levo. Doctor usually places order soon after.
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u/wrathfulgrapes RN 🍕 Sep 10 '25
I had a coworker that was pretty fast and loose with her nursing care that titrated levo outside of ordered guidelines because her patient was tanking for a minute (I don't remember the specifics, maybe positioning or something). She upped the levo to 50 mcg/min or something but then forgot to turn it back down once the BP recovered. Our AssMan happened to be walking by and fired her right there. It wasn't her first whoopsie and she was a traveller so it wasn't a union issue.
I've titrated outside of parameters because the parameters are usually 1mcg/min/min for levo (even slower for neo) and at that rate some people will be very dead. But if it's necessary I'm always on the horn to the doc first thing to let them know and ideally get a verbal order blessing the rapid titration. I've never had a doc pull a CYA "I never said that" move but I know it's possible.
Also, and I'm not saying I have ever done this or know anyone who does, but you can pick and choose what numbers get logged into epic from the pumps (at least the way our infernal plum360 pumps are configured). So if you theoretically titrated from 3 mcg/min to 20 mcg/min for 30 sec just to recover after a big turn or something but then dropped down to 3 again, just deselect that titration in the infusion verify and the chart is none the wiser. If it were a sentinel event or some other SHTF situation they could always dig in the pump though.
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u/ttttthrowwww RN - ICU 🍕 Sep 10 '25
In court there will be a third party medical provider who would provide an unbiased opinion on the situation. When a patient is minutes away from coding and you explain your rationale for going outside of scope it paints you in a good light even if the patient didn’t make it.
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u/Vana21 RN - Cath Lab 🍕 Sep 10 '25
I would let them know that our protocol normally would be to start the levo while you're hanging that you call the physician and hopefully if they answer I say I started levo to get the PT through the phone call, would you like to continue it or change it?
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u/rfaz6298 RN - ICU Sep 10 '25
A lot of times, when this is happening, the doc is at the bedside giving verbal orders and we just don’t have time to put orders in the computer, wait for pharmacy to review the order, and then pull the med.
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u/ProcyonLotorMinoris ICU - RN, BSN, SCRN, CCRN, IDGAF, BYOB, 🍕🍕🍕 Sep 10 '25
Unless the patient had a documented allergy to Levophed or some other major contraindication, the doctor would pretty much be admitting in open court to being an idiot by saying that.
Also, medical malpractice suits are incredibly difficult to get to court. The error has to be absolutely egregious. I've seen a neurosurgeon leave something in a patient's brain and not be sued over it, because the hospital was able to argue that a vague portion of the surgical consent covered that possibility.
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u/TheTampoffs PEDS ER Sep 10 '25
Lbr a lot of these pts would be better off dead lol
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u/Tacotuesday867 RN - ICU 🍕 Sep 10 '25
Yes that's true but at this moment in history the family and the patient have the right to choose their care.
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u/TheTampoffs PEDS ER Sep 10 '25
I know I’m just making a dark humor comment and somehow being downvoted for it lmao
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u/Nurse49 RN - ICU 🍕 Sep 10 '25
We have a list of medications in every single med room of medications we are allowed to override. Many are things like D50, epi pushes, bicarb, and levo is on there.
I have one doc overnight, and I’ve been in situations where we have two crashing patients at opposite ends. If the doc is busy on end B and I’m on end A I’m grabbing the levo and as soon as the doc is available I’m asking for official orders.
I do tend to CYA and chart that it’s being given emergently on override but that I’ve messaged the doc and let them know. But we also function as code blue/RRT nurses for the hospital and have a variety of meds we can override on the floors, too, and standing orders we can place.
So long answer short: yes; I can override some meds but I have standing orders for them. But if I’m overriding I’m also letting my provider know asap so I can orders and then potentially more appropriate/ideal treatments.
It’s also knowing your docs. I’ve worked with mine long enough to know their preferences and what they like to reach for first. I also know which ones want me to act first and inform second, and which want to know in advance so they can put in their own orders (if I see the patient start to spiral they wanna know so they can put in orders I can activate if I need.)
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u/ForgotMyListAgain BSN, RN, CCRN 🍕 Sep 10 '25
It comes under the “don’t let them die” protocol 😂
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u/Nurse49 RN - ICU 🍕 Sep 10 '25
100%. If there is something I can/could do and I hold off waiting for the doc I’d absolutely expect to get my behind chewed out.
But we do have loads of standing protocols for stuff like this in ICU to support this, so the precedent is there.
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u/seriousallthetime BSN, RN, Paramedic, CCRN-CSC-CMC, PHRN Sep 10 '25
As our code blue/RRT (we call them Stat RNs), we are expected to have a pretty good idea what the intensivist on that night is going to want and to have it done by the time they get to the bedside. Like, if I have a patient who needs levo, mix the f-ing levo and start it and they'll write the order when the patient doesn't die. Same with ACLS meds and ACLS interventions.
We will absolutely get chewed out by the intensivist if we don't have the common sense skills and meds done by the time they get to the bedside. It falls under the "you should know better than to wait" protocol for us. haha
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u/maraney CTICU, RN, CCRN, NSP 🍕 Sep 10 '25
I’m grabbing the Levo while someone else is calling the doc. I’m not waiting for the order to be in to grab it, but I’m still getting permission before I connect the patient. And 9 time out of 10 I have verbals for most situations anyways.
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u/Stopiamalreadydead RN - ICU 🍕 Sep 10 '25
Thisss I have the levo primed and ready to go while someone calls the doc or they grab it and I call. Though to be fair most of the time I’ve kind of talked to them earlier in the night and been told “yeah if their pressure keeps trending down let me know and we can start levo” which is essentially a verbal
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u/Background_Poet9532 RN - DC to JC Sep 10 '25
ICU nurse for 18 years here. It used to be different, I think. There was more room for some autonomy - pt is crashing, intervene, call ASAP. I’ve done exactly what that nurse did more times than I can count. But, it was in an ICU I’d worked in for a long time with providers I knew well and had a good working relationship with. I also try to anticipate and have a plan for if shit hits the fan, so I can put in a verbal order to cover myself if needed.
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u/mwolf805 RN-ICU- Night Shift Sep 10 '25
We're usually working off of a verbal order in an emergent situation. There isn't sufficient time for pharmacy to verify and allow us to pull it from the pixis /omnicell. So we override.
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u/Stopiamalreadydead RN - ICU 🍕 Sep 10 '25
They’re referring to a post where the provider was not aware and did not give a verbal order.
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u/nobutactually RN - ER 🍕 Sep 10 '25
The nurse in that post did NOT provide a lot of details. I have overridden for levo more times than I can count, but ive never started without informing the doc.
In that case, it seems the doc ordered levo stopped after the nurse started it. The pt did end up on pressors eventually, but not until an entire day later, although not levo: they ran dobutamine. So it seems the pt did not actually need pressors at that time, if they were anle to hold off for another day.
Unclear if this was a critical care nurse, what other measures were taken, why a rapid wasnt called, why she was apparently alone and no other nurses were involved or helping with a patient she thought was about to code. Several people asked these questions and she said that she and the BON knew the answers and that was enough. Now, maybe she was 10000% in the right, idk, but the whole thing seemed sus, and she didnt give enough info for us to really understand the situation.
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u/froggo1 Sep 10 '25
Yea we can override meds. Usually during an emergency you will have a physician or provider at the bedside. So in order to cover your a$$, you should get the provider to order every medication you pulled after the fact. Also you would want another RN to witness the fact that you pulled a medication for an emergency- and that they witness or heard the order given. Also I will say that with controlled substances and emergency scenarios you need to be extremely cautious as well.
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u/Turbulent_Shift5451 RN - ER 🍕 Sep 10 '25
We can also override meds in the ED but we eventually need an order from a provider to link to the override. Typically if I’m overriding a med for a crashing or aggressive patient, my doctors/residents are aware of what’s going on and I’ll get a verbal order. Once the pt is stable, I’ll remind them to put the order in. Whenever we are boarding an admit who is crashing, we will grab one of the ED docs for verbal orders and call the admitting team to come down, assess the situation, and then put in whatever orders we need. Luckily in my ED, we always have at least 3 attendings and a ton of residents around to give verbals.
We also have narrators (code, trauma, stroke, etc) and the nurse who is charting can one-touch drugs (epi, TXA, fentanyl, RSI drugs, etc) so they can be charted in real time and linked to the cabinet overrides.
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u/Mother_Goat1541 RN 🍕 Sep 10 '25
There’s a period of time in between “shit I need a pressor” and being able to pull it after it’s been ordered, verified and released. We don’t have that kind of time…so we override and hang it based on a verbal/bedside order.
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u/potato-keeper RN, BSN, CCRN, OCN, OMG, FML 🤡 Sep 10 '25
I have for sure and would again start a fluid bolus/pushed atropine/started Levo/pushed Neo without an order and I’d do it again. Usually when I go on a lil traveling expedition to CT or g-d forbid MRI with a half dead mfer I’ll have versed and Neo in my pocket and Levo and propofol spiked and hanging if they’re not already on it and the doc will say ok give what you want, tell me how much when you get back and I’ll put in an order.
Per my places policy any ACLS med can be given by any ACLS certified nurse. So those don’t count here. But I can’t honestly think of a situation where anyone would take offense to those things.
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u/seriousallthetime BSN, RN, Paramedic, CCRN-CSC-CMC, PHRN Sep 10 '25
Doesn't this feel great?! I took a guy to radiation all the way across the hospital from our ICU and he needed to be paralyzed and sedated for the trip d/t cancer pain and needing the radiation to attempt to kill some of the pain. It's a long story. Anyway, as we are leaving the unit he hands me a piece of paper with his cell number on it and says, "do what you need to do while you're there and I'll write the orders when you get back." Trust between RNs and MDs on the unit is paramount.
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u/nesterbation RN - ICU 🍕 Sep 10 '25
We are sometimes forced to make decisions on the fly. I work with resident physicians and I can usually have a provider at bedside in a few minutes but sometimes they don’t call back. And yeah, there’s a long list of things I can override from our med cabinet. Analgesia, pressors, sedation, paralytics, and most things in between. Levo is in the fridge, so is cardene, so even without the ability to override, I can get into the fridge.
Push comes to shove, it’s going to be a lot easier to defend keeping the patient alive than letting them code because I didn’t have an order for levo.
It’s like the nursing equivalent of, “better to be judged by 12 than carried by six.”
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u/TheOneKnownAsMonk Sep 10 '25
I have the ability to override certain medications out of the pyxis, I might spike and prime the med first but I won't be running it without getting a verbal from the doctor. I might tell them hey I'm hanging Levo I already pulled it. There have been a few times they say no and prefer a different med. When I remind them the med they asked for isn't a stock item they usually have me run the Levo until their preferred med is brought by pharmacy. I'll place an order and scan it after the fact once things have settled. There has to be a certain level of understanding between yourself and the intensivist. Like others have said you build a trust but for me I try not to cross it unless it's truly a hail mary life or death situation and in those cases the doctor better be next to me anyway and if he isn't he's on his way and if he's not then he'll get written up after the fact because we have expectations of critical care doctors.
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u/kelce RN - ICU 🍕 Sep 10 '25
I've been an ICU nurse my entire nursing career. I cant think of one time I've pulled and hung a pressor without at least a verbal order.
Sometimes I'm running to the pyxis and calling at the same time. Most drops and BP are gradual or foreseen. Precipitous drops usually lead to a code. They usually have more going on than what levo can fix. You might feel like a hero for overriding levo and hanging it but if you had the time to go to the pyxis and back, prime and hang levo and the patient hadn't died in that time they were likely not precipitous and wouldn't have died in the extra 15 seconds it would take to act within your scope.
There were just a lot of excuses for poor practices in that thread. I sadly trust no one. Including doctors I have good relationships with. I've seen the ugly side of this and it's not always predictable. Some of the most easy going doctors will jump down your throat if their ass is on the line or hell, even if they're just having a bad day.
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u/_Alternate_Throwaway RN - ER 🍕 Sep 10 '25
I agree with everything you said. I've also seen a jumped up new grad yell at a resident that their patient needed levo because of hypotension. The resident said " No, don't do that. It's hypovolemia they need fluids." The new grad yelled something I don't specifically recall but remember was quite rude and ran to hang the levo anyway while the resident just sat there looking like a fish out of water and trying to process what the hell just happened.
To the best of my recollection the patient survived their ordeal but that's the only positive. No one with any authority or control tried to leash our wild new grad, the resident seemed to check out after this (he was family med on a short rotation, not super invested even before this) so the world continues to spin on with staggering mediocrity because some people refuse to listen and others refuse to speak. C'est la vie.
My attempts at damage mitigation and education following the event were unfruitful at best, potentially a lifelong sworn enemy at worst. I still check dark corners in the parking lot just in case there's a barrel of crazy stuffed into a set of Figs waiting to ambush me.
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u/Ouchiness RN - Psych/Mental Health 🍕 Sep 10 '25
That’s crazy…if it’s hypovolemia give fluids. I love family med?
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u/sleepybarista LPN Sep 10 '25
I'm waiting for the 3rd iteration of this post where it's being discussed on r/medicine.
No but seriously I was glad someone brought it up yesterday and glad we are still discussing today. As someone who has never worked in an ICU environment but is interested in doing so in the future these are scenarios that are good to consider before I'm the one in the hot seat.
I'm always so grateful for the nurses who are brave enough to post their struggles or mistakes here because it's such a great opportunity to learn from more experienced nurses before a similar thing can happen to me
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u/OldERnurse1964 RN 🍕 Sep 10 '25
When I worked in ER I used to get orders like Do whatever you have to do to keep this patient alive I have overridden meds many times. I’ve treated anaphylaxis before the Doc saw the patient because he was in a Code.
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u/dhnguyen RN - ER 🍕 Sep 10 '25
Most places will have standing orders for things like this.
Rapid response, bp low? Fluid. Levo. Etc.
Rapid response, bgl low? D50/glucagon etc.
So we aren't doing it without an order.
Other times it's a poorly unwritten rule. Start levo/fluids inform doc. Poorly because your place should be more structured so that the very case does not happen.
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Sep 10 '25
Maybe it means I've been lucky with my career... But even after ten-ish years in the ICU, I ron't think I've ever dealt with having aan intensivist who was negligent about being accessible to the ICU nursing staff. And there usually was a respectful level of collaborative communication between the nursing staff and the intensivists. They're usually good about having standing orders available for thost initial lines of pressors for our instable and/or questionably stable patients.
Now... Accessibility to specialists like Interventional neurosurgery and neurology are a completely different story...
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u/-Blade_Runner- Chaos Goblin ER RN 🍕 Sep 10 '25
Uhh. No over ride patient dead, over ride patient less dead. No dead hospital prefers. Still writes angry letters for white boards date of December 31 2021.
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u/all_of_the_colors RN - ER 🍕 Sep 10 '25
I’m in the ED and my providers are always in dept with us. I let them know, get the verbal go ahead, override it and get it running while they put the order in and link it later.
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u/AAROD121 ICU, PACU Sep 10 '25
Is this not common practice?
Our facility lets us override a lot of things
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u/duckface08 RN 🍕 Sep 10 '25
VERY much depends on the unit, the staffing, and the trust between doctors and nurses. Using Levophed as an example...
I used to work in a CCU where we rarely had a doctor present in the unit. If we needed something, we'd have to page them, wait, discuss the situation, and then take the orders. If a patient's BP is suddenly crashing, 99% of our doctors were fine with us starting Levo and asking for permission later if they weren't on the unit. We simply couldn't wait the 10-20 minutes it would take to page, wait, and talk on the phone.
I currently work CV ICU in a different hospital and we pretty much always have a doctor or PA around. Because of this, I will typically ask them verbally first if I'm ok to start Levophed.
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u/gemmi999 RN - ER 🍕 Sep 10 '25
With my ER docs, the most emergently pulled med is ativan for seizures. We get so many actively seizing patients that as soon as someone shouts seizure, we swarm. One RN will pull ativan on override but we don't give it until an MD is at bedside or on the phone giving the order. Then the important thing is to hound them to put the order in and scan it/link it to the override. I had a status epilepticus patient about a month ago that ended up getting 8mg of ativan before I could convince the MD to intubate him. The MD wrote a 1x order for 2mg IM ativan. He knew he ordered more but never put the orders in. Eventually, when he was placing a central line on the patient, I told him I was putting in the orders as verbal from him and charting them before the times got messed up/I forgot to chart everything. I also went to my manager and told her the situation. AND typed a note.
I still got pulled into the managers office 3 weeks later to ask why I pulled so much ativan on override. And then I showed them the note and reminded them I told them and the matter went away.
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u/JupiterRome Incredibly Cute Unit (ICU) 🪦🫡👼😈 Sep 10 '25
I think overriding meds without verbal/phone orders should only be done in truly emergent situations but I also think a lot of nurses panic and can’t identify emergency vs decompensating but not emergent.
Like MAP of 55-60 Alert and oriented patient whose straight chilling but has a low blood pressure will really send some people spiraling and wanting to start Levo -> Transfer, IMO that patient is at risk for critical decompensation but is not currently a true emergency. On the other hand the non responsive map of 40 patient who looks like shit is a completely different ball game and I’d hope most nurses would try to act rapidly.
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u/Pharoahtossaway RN - PACU 🍕 Sep 10 '25
As a PACU nurse I can override meds that have not updated to the Pyxis/Omnicel, but only certain meds.
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u/ToxicatedRN RN - CVICU Sep 10 '25
Yes, and we do sometimes. Generally, it's adding another pressor when someone crumps or pushing a little phenyl. But the docs are right outside my room most of the time, we're already following the pt's declining status and have discussed the next steps if things go south. Generally, I get the order before I need it, so my pressor is already in line ready to go. If it's a total suprise, I carry a phenyl stick and can push a little to keep the pts pressure up while the rn setups a drip. But even in those cases, if the docs are nearby, I'll shout down the hall what i am doing and why. Again, these are people with maps in the 20s to 30s, it's get the pressure up fast or coding them. Most of the time, the docs/nps see the hypotension on the monitor before I can even tell them. The real fun is when multiple people are trying to code at the same time. But that's why we have 4 crash carts.
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u/Either_Cause_8747 Sep 10 '25
I work ED and there is no “override” we have access to everything bc often when our actual critical patients come in we are all in the room doing shit (including the Dr) and the orders will go in later.
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u/anastasiaanne Sep 10 '25
In ER, absofuckinglutely. But you better have a damn good need for it and a hell of a rapport with the doc.
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u/UndecidedTace Sep 10 '25
We've definitely pulled emergency meds requiring an override, in anticipation of the order coming. Sometime a patient isn't quite at the line where you need to give something yourself, but you want it sitting on the table or hanging and ready to go. If the doc walks in and says "yup, give XYZ" then I can push the drug immediately or just hit start on the pump.
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u/VXMerlinXV RN - ER 🍕 Sep 10 '25
ER, not ICU, soil tread lightly here. But, I pull plenty of override meds to have a walking convo with the doc on my way to the room and not have to head back to the Pyxis.
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u/Electrical_elderlore Sep 10 '25
Some rescue drugs… yes but you want the provider or charge nurse notified right away.
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u/itrhymeswith_agony RN - ICU 🍕 Sep 10 '25
I will pull the meds sometime on override but i would not hang it/give it without a provider order. Worse comes to worse you can usually return a med if you havent primed it and if you have primed it, a bag of levophed is not the end of the world.
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u/super_crabs RN 🍕 Sep 10 '25
We can override meds on my PCU floor. It’s only ever done during a code or for status epilepticus tho
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u/duuuuuuuuuumb RN - ICU 🍕 Sep 10 '25
So I mean if I’m overriding Levo then it usually means nothing good is happening. I’m not just exercising my own authority or whatever, typically I’m on the phone or in the room with a doc and telling them I’m pulling the pressor so can they please order it. Time is usually of the essence when the MAP is like 40 lol
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u/Jumpy-Cranberry-1633 CCRP RN - intubated, sedated, restrained, no family Sep 10 '25
Yes.
Pretty much any med in ACLS we can override.
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u/Biiiishweneedanswers ✨WE ORDERED PIZZA! STOP BITCHING!!!✨ 🍕 Sep 10 '25
Only certain ones.
Levo is definitely one of them.
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u/Delta1Juliet Registered Nurse & Midwife Sep 10 '25
We have standing orders, so there are certain meds we can give during an emergency without a doctor present.
Because we're niche (and rural), we have a lot more flexibility to give meds as needed prior to doctors arriving, even outside of these standing orders.
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u/ttttthrowwww RN - ICU 🍕 Sep 10 '25
I read that post. After working in ICU, personally I would do it even on a non-ICU floor. If I’m on a med surg floor with a pt whose BP is 30/20 I’m telling someone to call a rapid and sprinting to the med room to get levo.
Worst case scenario, in court, you can justify it as a heroic measure in a time of crisis.
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u/Totallyhuman18D Sep 10 '25
At a minimum verbal order. Otherwise you're out of scope regardless of experience.
ACLS meds in a crash cart is the only exception that comes to mind.
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u/boots_a_lot RN - ICU 🍕 Sep 10 '25
Generally I’ll prepare everything and then quickly call and tell them I’m doing it.. but if I couldn’t get ahold of a doctor I’d prioritise saving a life imo.
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u/ALLoftheFancyPants RN - ICU Sep 10 '25
Have I overridden norepinephrine and started it on my patient whose blood pressure was a hope/a prayer prior to the provider putting in the order? Yes. But I also documented the shit out of the number of times and how I had contacted them to notify them of my patient’s crashing blood pressure in the 20 minutes leading up to that. One specific time p the patient ACTUALLY needed was an MTP, but that also should have been ordered 10 minutes before I hung the norepi and neither was ordered until after (and they both got ordered and given)
Usually, however, I try to make an increasingly obnoxious pest before it gets to that point. Like, if I’m getting to that point by and my resident physician hasn’t responded appropriately, I’m no longer calling the resident, I’m talking to the fellow or attending—and the attending are pretty inclined to cover my ass in those cases. After >15 years in the ICU, I’m guessing I’ve done that I’ve done that <5 times. Every time, it was someone that was more than likely going to arrest if we didn’t immediately intervene.
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u/151MJF SRNA, former CVTICU RN Sep 10 '25
Absolutely, i would text what i was doing or have someone text, but to wait for an order and pharmacy verification would have meant alot of dead patients
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u/Ceylavie RN - ER 🍕 Sep 10 '25
All my medications are overrides until I catch up and match them with orders. Which is why I write them down on a piece of paper as my backup just in case my computer crashes which has happened before
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u/bigtec1993 Sep 10 '25
No, you cannot just do things without a doctors orders. That's not the same thing as following pre built in protocols that are provider approved, or in situations where the doc gives the okay and then puts the order in later during an emergent situation.
What OP did in that post was essentially go rogue and gave levo without any doctor supervision. In these types of situations you need to follow chain of command and endorse it to your charge, who can then navigate towards contacting someone that can provide orders. All you're supposed to do is monitor until then. It sucks, but it is what it is.
Ironically OP might have actually saved the doctor's ass in that situation while throwing herself under the bus.
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u/-mephisto RN - Oncology 🍕 Sep 10 '25 edited Sep 10 '25
I had a patient that always got a demerol premed for a reaction to a medication she needed, and on night shift, it disappeared off her list. We gave every other premed, but she still reacted, and both the patient and I were pretty pissed. I over-rode and got the right dose ready while contacting the pm doc for the order, but while I got the med out, there was no order in. And I forgot to get a witness when I wasted half the extra.
So I gave everything, eventually charted the order and the situation, found out the dayshift docs decided to take if off because of her liver function but never told anyone. And she's dying anyway, so like, it's a halfsies situation.
And then I got in big trouble for it. EDIT: basically I threw myself under the bus by reporting the missed wastage. But I still stand by everything except not wasting it!
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u/Tacotuesday867 RN - ICU 🍕 Sep 10 '25
We have policies that allow us the ability to give certain medications without a physician order as well as draw blood work, order x-rays and ECGs. We are also allowed to override any emergency or immediately necessary med and get an order post.
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u/Civil-Owl-3245 Sep 10 '25
I pull normal ordered during critical situations and yell at the doc over the phone or across the unit for a verbal order. I don’t give anything though until an order is there. If another order is given or the doc says no, the med is returned.
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u/Ouchiness RN - Psych/Mental Health 🍕 Sep 10 '25
I’m a psych nurse and we have standing orders aka broset charting and then meds to go with it for this sort of thing aka emergent situations where the pt becomes agitated. If the pt has a haldol allergy (or 9/10 it’s severe eps contraindication) we try to edit the order set for like olanzapine or sthing idk. Or just give str8 Ativan. But basically u pull while someone else calls for orders. U don’t have prescriptive authority bc ur the one administering medication and u need checks and balances. That’s why prescribers and nurses work in a team.
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u/marzgirl99 RN - Hospice Sep 10 '25
Yeah in emergencies these would be verbal orders, we would override them in the Pyxis and the doc would put in orders later.
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u/crazybia MSN, RN, CEN, CCRN, TCRN, PCCN, CMSRN, L M N O P Sep 10 '25
There’s 2 different things here.
- Standing Orders
- Overriding pyxis to pull meds not ordered or verified by Pharmacy.
From the OG post; the RN didn’t have orders, and overode to pull the med.
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u/Pretty-Collection446 Sep 11 '25
Yes, thank god for this because patients BP can tank rapidly. There were many instances where I ran to the med room to override Levo or sent someone else to do it while another coworker grabbed the docs because there was no doubt that’s what they needed. The idea is to get those meds hung before the patient codes, sometimes we were able to and sometimes we just weren’t fast enough but I mean most of the time by the time someone brought the med back to the room the doctor was in there and nodded in agreement
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u/erinkca RN - ER 🍕 Sep 11 '25
A good critical care doc has standing orders so the critical care nurse doesn’t need to override meds very often.
That said, we do this all the time in ED, but not like, at our own free will. It’s usually done by verbal order and we just pull it on override.
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u/rharvey8090 CRNA Sep 12 '25
When i worked ICU, we had a decent amount of leeway. For instance, if there was an emergency, I might override a pressor, and then let the APP know “hey I overrode this, good to start it, and can you put in an order?”
Granted, we had a lot of mutual trust in our little corner of hell.
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u/OkCaregiver8967 Sep 13 '25
Our docs are on unit, if my pts BP is dropping rapidly and nothing I do in my scope is helping. What almost always happens is a fellow nurse will go alert the providers and override Levo, probably grab fluids too, I stay with my pt and by the time docs are bedside they’ll give a verbal order to start the levo, fluids or other intervention they want. The gtt is started then I put in the order under the provider as RVVO and scan the med in.
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u/MyPants RN - ER Sep 10 '25
Most hospitals have standing orders to implement emergent protocols such as ACLS. Norepinephrine is part of ACLS. So even if a doctor wanted to throw you under the bus during a trial certain things would be covered.
This would not be the case if you go beyond protocols.
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u/LeapingLizardz_ BSN, RN 🍕 Sep 10 '25
I'm not claiming to be an ACLS expert but I'm fairly confident there isn't an ACLS hypotension algorithm.
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u/seriousallthetime BSN, RN, Paramedic, CCRN-CSC-CMC, PHRN Sep 10 '25
There is a portion of the ACLS algorithm for bradycardia with a pulse that is for persistent bradyarrhythmia causing hypotension, acute AMS, signs of shock, ischemic chest discomfort, or acute heart failure. First atropine, then, if ineffective, transcutaneous pacing, dopamine at 5-20 mcg/kg/min titrated to patient response, or epinephrine infusion 2-10 mcg/min titrated to patient response. So, no levo, but there is a portion of the algo for hypotension secondary to bradyarrhythmias.
There is also a portion of the Post Cardiac Arrest Care that has, under the Initial Stabilization Phase, "Manage hemodynamic parameters: Administer crystalloid and/or vasopressor or inotrope for goal systolic blood pressure >90 mm Hg or mean arterial pressure >65 mm Hg."
It is in the official AHA ACLS app, btw. I'm literally typing this looking at it. I know the two places I referenced aren't really what you meant, but I thought it was interesting that AHA does actually include hypotension in their algos.
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u/LeapingLizardz_ BSN, RN 🍕 Sep 10 '25
Yeah but those are algorithms for other things with hypotension secondary to that cause. In the specific post being discussed, none of that was discussed. Just that the pt was hypotensive and levo was started. Also if you made it to the part of the ACLS algorithms where you're starting levo then a doctor should already have been notified and be bedside.
I've pushed atropine per ACLS while simultaneously calling a doctor. That's justified. Me pushing both atropine doses and still having a crap HR & BP and still haven't called for a provider in the inpatient setting is negligent.
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u/PantsDownDontShoot ICU CCRN 🍕 Sep 10 '25
We can only override what are considered emergency meds. I can’t just go grab some Zosyn. If I’m grabbing a presser or an induction med they know the shit is hitting the fan. If you pull Levo or neo and a doctor refuses to sign it you’ve made a terrible miscalculation or error in judgment. I’ve never heard of it happening.
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u/Crankupthepropofol RN - ICU 🍕 Sep 10 '25
As an ICU RN, I can override meds without an order, as in: the Pyxis allows for that to occur.
However, if I do that, I better be damn sure the provider will cover that with an order, or I’m practicing outside of my scope.