Nurse Discontinues Telemetry Order Without Physician Approval


Nursing Expert

This case involves a female patient with COPD who was administered large amounts of tranquilizers. The physician ordered the patient to be placed on telemetry, however, the nurse on call discontinued the order without the doctor’s confirmation. Hours after receiving the tranquilizers, the patient was in cardiac arrest. The patient was resuscitated and intubated but turned blue and passed away before the physicians could move her to the intensive care unit. It was later discovered that the nurse had placed the endotracheal tube in the patient’s esophagus instead of the trachea. An expert in nursing with a great deal of experience working in a telemetry unit was sought to review the records and opine on the standard of care.

Question(s) For Expert Witness

  • 1. Please describe your background in nursing.
  • 2. What is your experience working on general medicine floor and in a telemetry unit?
  • 3. If a physician orders a patient to be moved to a telemetry setting, is the nurse able to cancel that order without informing the physician?
  • 4. After a patient is intubated, whose responsibility is it to check for proper tube placement?

Expert Witness Response E-122210

I have been a nurse for 22 years in a variety of care settings with a variety of patient populations. I currently cover the entire spectrum of hospital care. I have represented plaintiffs who have expired as a result of hospital negligence. In this situation, based on what you have provided, the nurse would not be able to D/C telemetry without an order from a provider. Had this patient been on the ordered monitoring with alarms on, the staff would have been notified when heart rate or oxygen levels dropped. During a code, typically the respiratory therapist does the initial placement check by listening for bilateral breath sounds, and either the provider or respiratory therapists will place a commercial end CO2 detector on the endotracheal tube. Once the crowd clears, it becomes the nurse’s responsibility and the respiratory therapist’s responsibility to confirm a patent airway. The nurse would be monitoring vital signs, including oxygen and clinical assessment. The provider would order a chest X-ray to confirm as well. This should have been completed after the transfer to ICU because moving the patient can dislodge the tube. One would think that if they suctioned the endotracheal tube, which they should have done, they would likely have gotten stomach secretions. In the ICU, the patient should have also been on end tidal CO2 monitoring, especially given the COPD. In regard to being on telemetry D/T large doses of benzodiazepines, this would depend on PT history, ordered dose, and frequency.

Expert Witness Response E-008244

I have worked on medical, surgical, and cardiac step down/telemetry units, and for the past 5 years, in cardiac ICU or CCU. Ideally, this patient should have at least been placed on pulse oximetry. Telemetry might have been necessary as well, although I would need to know more about the patient’s history. However, a COPD patient with high tranquilizer doses should be monitored with oximetry and, depending on the dose, end title monitoring. Unless instructed by the MD, no order for telemetry should be canceled without first clarifying with the physician. Placement of endotracheal tubes is confirmed in a number of ways. Typically, the MD will place the tube and the respiratory therapist will ventilate and auscultate for breath sounds. CO2 confirmation can be performed if supplies are available in the facility. Cuff tension can also typically be checked by the respiratory therapist. The standard is to place some sort of visual tool, like a glydoscope, to ensure visualization of the mainstem bronchus and bifurcation at the carina. X-ray is the gold standard post-intubation, particularly in an emergent intubation without visualization. The patient’s vital signs should be checked continuously post-intubation, especially pulse oximetry and end tidal CO2 monitoring while on the ventilator. ICU placement is the standard in the immediate post-intubation period for this reason.

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