Do you know your hospital’s policies and procedures?  Do you follow them?

If you have worked at numerous places, you probably have noticed that each hospital has its own specific policies and procedures.  It may never occur to you to look up the policy or procedure on something because, as the saying goes, “We’ve always done it this way.”

But, be careful!

There are variations in the policies and procedures of facilities.  At one facility you might draw blood from a central line but find that if you then go to another facility and assume that you could draw blood from a central line, you may want to think again.  Or at least check the facility’s policies and procedures to be sure.

Should you be practicing outside the scope of your practice, that is a violation of the Nurse Practice Act.  The policies and procedures will save you every time!

Let’s say you work in a facility where a physician normally orders a certain medication for post-op pain and the orders are not in the system yet, be careful of overriding the Pyxis.  I know this is counterintuitive because you want to help the patient with their pain and you know that the doctor always orders the same medication.  However, overriding the Pyxis without the physician’s order is a violation of the policies and procedures.

Lastly, if you work in a facility where your supervisor tells you it is okay to use the orders prior to transfer while the policies and procedures require you to obtain new orders, you’re in violation of the facilities policies and procedures.

As much as we want to help our patients and expedite care, we must be careful to be sure that we are doing things “by the book.”  Any deviations outside your policies and procedures could cause you to be in trouble.

If you don’t know those policies and procedures, go review them as soon as you can to educate yourself and ensure that you are following them.

You may be surprised in what you find but more importantly you will also be better able to protect your patients and your license.