Registered nurses and physicians caring for hospitalized patients share a lot of responsibility and tasks. When it comes to medications, though, the decision to start or stop a drug is one that falls in the doctor’s lap.
In 2019, an intensive care unit (ICU) registered nurse at Houston Methodist Willowbrook Hospital learned this the hard way. Based on the nurse’s mistake, the Centers for Medicare and Medicaid Services issued a violation to the hospital, on May 21, 2019, related to administration of drugs.
Houston Methodist Willowbrook Hospital is a 312-bed regional hospital located in northwest Houston at 18220 Tomball Parkway, Houston, Texas 77070.
Medication orders and administration
Under Texas law, registered nurses are not allowed to order medications or discontinue them. These are responsibilities reserved for licensed physicians and, under some circumstances, mid-level providers such as physician’s assistants and nurse practitioners.
The role of registered nurses is to receive medication orders and make sure that the drugs are administered as ordered. This includes giving the correct drug and the correct dose at the correct times.
The Texas Board of Nursing requires nurses to be aware of the rationale and effects of all medications that they administer. The standard of care mandates that nurses assess patients before giving a medication and to reassess them at an appropriate time after the drug is administered.
When a nurse develops a concern based on assessment or reassessment of the patient, the nurses aren’t allowed to stop a medication without advocating for the patient safety by communicating with the physician, and then documenting the concerns and communications in the patient’s medical record.
The problem at Houston Methodist Willowbrook Hospital was that the registered nurse decided to discontinue a patient’s properly-ordered blood pressure medication without notifying the ordering physician.
A doctor had ordered a clonidine patch for an ICU patient. Clonidine is a prescription drug used to treat high blood pressure (hypertension). When administered as a patch, Clonidine is left on the patient for three days.
The ICU registered nurse felt that the patient’s systolic blood pressure had dropped too quickly, from 172 to 110 in around an hour (the textbook definition of a normal systolic blood pressure is 120), and decided to stop the patch without consulting the doctor.
The nurse’s decision left the ordering physician in the dark. Plus, the nurse didn’t document in the medical record why the ordered medication clonidine was not administered or delayed, which is required by the hospital’s own policies and procedures.
It would’ve been simple for the nurse to pick up the phone and speak with or page the doctor. This type of patient-focused behavior is called nursing advocacy and is drilled into every nursing student. In my experience as a former hospital administrator and now as a long-time medical malpractice lawyer, if a registered nurse called the physician with a patient safety concern like this, it’s almost unquestionable that the doctor would order the medication delayed or discontinued.
While in this case, it’s my opinion that the nurse’s reasoning was sound, it concerns me that the nurse didn’t realize that he needed an order to hold a medication in the first place.
Based on the limited details in the Medicare violation issued to Houston Methodist Willowbrook Hospital, we can’t know for sure all the factors that were at play in this nursing mistake. In my experience, though, many Texas hospitals don’t hire enough nurses to provide safe and proper care to their patients.
When nurses get busy taking care of too many patients, some tasks have to suffer. In many cases, we’ve seen that nursing advocacy and physician communication are sacrificed. This sometimes means that doctors aren’t timely informed about important lab or radiology results, medication issues, or clinically-significant changes in patient status. From there, things can snowball, with delays in diagnosis and treatment causing real patient harm.
If you’ve been seriously injured because of poor nursing, hospital, or physician care, then reach out to a top-rated experienced Houston, Texas medical malpractice lawyer for help.