Had one before, went all the way to the pharmacist, and a bit shy of the administration, until I was proven right.
Had a carotid patient admitted to the telemetry unit that required 100mg of regular metoprolol twice a day, per his medication list he kept on him. Not believing it myself, I ran through the primary doctor's electronic medication reconciliation, (part of the regional health system, and he was in our network,) and found it to be correct. Wrote the order, and it should have been a done deal.
Nurse refused the order, thinking I made a mistake of reading a computer readout from a dictation on the dosage.
They swore it had to be metoprolol SR at that amount, and charge nurse of the unit and the pharmacist both gave me a chewing, with the threat of reprimand, despite the evidence I had that stated otherwise. Seniors backed me, fortunately, and I refused to lose my cool or be hostile about it, standing by my guns and the evidence that was in permanent record. Nevertheless, I was overridden by bureaucracy and it was given as SR.
Unknown to the nursing or pharmacy, the primary doc put him on that schedule of regular metoprolol because SR didn't give him enough control. They gave the SR in the morning, as he had enough beta blocker during surgery to last him through the night. The SR dose didn't touch his blood pressure, with systolic in the 160's-170's. heart rate never dropped below 100. Mind you, nursing was panicking because he was setting off his telemetry warnings until one thing happened.
I re-instated the correct dosage of regular metoprolol.
Within an hour or so after the correct dose was given, the patient's systolic was 100's-120s, with pulse of 70's-80's for the rest of his time on telemetry. Seniors got a good chuckle the junior resident (me) showed up this particular charge nurse, and this ward, both were a pain in their semperini.
Never got an apology from the charge nurse or pharmacy *shrug*. They dropped the threat of reprimand. Though no one ever questioned my orders on that unit again. I made an addendum to the online med list to clarify the metoprolol was regular, immediate release to prevent future muck ups.
Learning points:
1. Make sure you got the right order, and make sure you can back it up.
2. Be nice, despite their threats, yelling and screaming. You as the physician have to be the voice of reason and the calming influence when things hit the fan.
3. Realize that both sides are looking after the best interests of the patient. We have the backing of our knowledge base and critical thinking. Nursing has their protocols in place to keep them from hurting the patient. I have fortunately not encountered apathetic nurses.