Digoxin Error, How should it be handled? Worried for a Pt.

SuesquatchRN, BSN, RN · Jul 27, 2008

I don't remember if I clarified in my original post that this was my second day orienting, and as a new graduate.
I was "shadowing" an RN, and all I knew to do was report to her, and bring it to another nurses attention at shift change.

Which is precisely what you are supposed to do.

:)

Noryn · Jul 27, 2008

So, I'm wondering what really should have been done...
how urgent was this, considering that even on the half dose his heart rate was only 50...
and also considering that going one day without the Dig, his heart was too erratic to count, shouldn't something have been done?

I'm feeling very worried about this patient, but don't know if I'm being a newbie or if I'm right in thinking that this was an urgent situation.

You should get the patient's chart and check the actual doctor's order. Was it a transcription omission or error vs a pharmacy error. If you are giving medication then in all likelihood you did at least a quick assessment. With a hr of 50 you need to get a blood pressure and determine how the patient is tolerating this. ? dizziness or shortness of breath? Any s/s of digoxin toxicity? Then you would make the decision to contact the doctor or in your case, notify the preceptor.

The urgency depends on the entire picture. A heart rate of 50 does not always need an immediate ER eval but at the same time should be addressed as soon as possible. Make sure you have an order to hold digoxin if heart rate is less than 60. If you dont have an order, hold it for the time being and contact the doctor (within a reasonable amount of time).

Again if his heart rate was irregular then further assessment is in order. The doctor should be made aware. They may want ER eval or order an EKG. If the pt is doing ok, blood pressure is ok and pt has a history of a fib then the doctor may feel comfortable in restarting the digoxin.

Unfortunately there seems to be an abundance of apathy in some long term facilities.

mpccrn, BSN, RN · Jul 27, 2008

could the previous shifts been giving him 2 of the 0.0625 doses? something to think about.

kstec, LPN · Jul 27, 2008

LPN's are in charge of themselves in LTC. We don't answer to RN's. It would of been the nurse whether it be LPN or RN to contact the MD. As for her being on orientation, in the future always look at the original order and then look to see if on the POS's that anything has changed with the dosing and why. If you find no new orders, than write an incident report, contact the MD and ask if any tests need to be performed. Always be cautious if something doesn't seem right. Your gut instinct will help you a lot in the futrue.

SillyStudent, ASN, RN · Jul 27, 2008

LPN's are in charge of themselves in LTC. We don't answer to RN's. It would of been the nurse whether it be LPN or RN to contact the MD. .

I am totally sure that an LPN is able to effectively communicate to an MD that there is a med error or question. (Especially since my MIL is the smartest Nurse on the entire planet, and an LPN)

However, aren't LTC facilities required to have an RN in charge of every shift?

Correct me if I am in error....I usually am....lol.

:jester:

SuesquatchRN, BSN, RN · Jul 27, 2008

The LPN in question was orienting under an RN.

It depends on the state and facility. In NY an RN is only required for 8 hours a day.

If you are working under an RN she contacts the doctor. If the LPN is charge she does.

Coastie_wife · Jul 27, 2008

I am totally sure that an LPN is able to effectively communicate to an MD that there is a med error or question. (Especially since my MIL is the smartest Nurse on the entire planet, and an LPN)
However, aren't LTC facilities required to have an RN in charge of every shift?
Correct me if I am in error....I usually am....lol.

LTC facilities are usually required to have at least 1 RN in the building on each shift. Mainly for the instances one is needed to do a pronouncement of death. Otherwise, basically the LPN is on his/her own. The only time we report to an RN is if it is the ADON/DON or the unit manager/supervisor is the RN. Most of the time on 2nd and 3rd shifts, your only RN is one who is working a floor too, not necessarily a supervisor, and you still would be expected to report something like this to the doctor yourself.

TiredMD · Jul 29, 2008

technicalities! At half the dose the pt serum dig level would be too law to cause harm. The issue is, is his heart rate now too fast (which would lead to a mural thrombus)? Does he need to be rebolused with dig? Yes it is a med error and you need to follow your facilities policy. Digoxin is becoming less popular over the past ten years. There are other ways of managing A-fib without using dig. With the increased use of Beta blockers and EP studies and Atrial ablations, afib and the use of digoxin is now more managable than ever in my life time. Many cardiologist just opt for a single chamber pacemaker and put the patient on beta blocker therapy and not fool around with serum blood levels and digoxin. For nearly 1000 years, digoxin has been used as a poison and with the difficulty in managing serum blood levels monthly.... it's starting to fade away. Much like in my days when I first got out of nursing school, we still used dilantian for heart failure and as an anti-arhythmic.

I'm betting the patient's blood pressure couldn't tolerate the beta-blocker, for whatever reason.

The reason the OP has to tell the physician is that he/she's not just dosing the dig based on serum level, but also clinical effect. For however long they've been looking at the heart rate in the 50s (okay) and the MAR showing 0.125 given. You start giving 0.125, and the heart rate runs the risk of crashing out.

The real problem isn't just the impending bradycardia, it's that it's not going to show up for a few days (long half-life on that drug). Then all of a sudden you've got a patient with symptomatic bradycardia for no "apparent" reason (since they've been getting a stable dig dose, according to the MAR). Great, now in addition to the risk of death, you just bought this poor elderly person a full cardiac workup for no good reason.

I think the OP should just tell the doc. When I get calls like this, my first response is, "Oh good, keep them on the lower dose." Certainly not something I'd make any kind of a big deal about.

WVStarFish · Aug 1, 2008

I know here in WV, in LTC, there does not have to be an RN on shift. There is never an RN on evenings or midnights here at this facility.

The LPN here does everything, except assessment and only other legal matter, it escapes me right now.

Thank you all for giving me so much information, and the MAR/pharm discrepency...I brought it to someones attention who will change it.

Unfortunatly, I have found many more med errors of similar circumstances. After only a few weeks doing this, it seems it's all about looking good on paper.

surviveslu · May 20, 2011

you have a nursing license.... it is your responsibility, if he is your patient, to notify the physician. it is my understanding (i don't work in a long term care facility... but i owned several aclf's in the past and have an administrator license) that an assesment still must be done and changes in a patient status must be communicated to the physician and documented. sss or tachy-brady syndrome is usually managed with dig (esp in managed care patients) or in the manor i discribed above.. with beta-blockers and a single chamber pacemaker. un-controlled rapid hr can lead to embolization, cva, syncope, chest pain and other issues if not treated. complications are likely to cost more health care dollars if he is not treated.this is why it is important for nurse to do there jobs.

if a pt stands up and within a minute, his heart rate goes back and from from 113 to 134 to 120 to 144...would you consider that real and report it to the md or wait to see that the hr stabilizes at a certain number, before calling the md?