Is this a system flaw? - page 2

by MonkeyLPN 2,707 Views | 17 Comments

I will say that I did make a mistake, but was my mistake a system flaw? We had a new admit on my floor about two weeks ago. When the meds were written in the MAR there was nothing stating that there needed to be a lab draw on the... Read More


  1. 1
    It's a system flaw! The OP is unorganized and wasn't proof read and the screen name speaks for itself, but labs get missed in extended care (it is extended care right?) all the time. I believe the responsibility to implement a reliable system lies with upper management. Placing blame in a case like this is completely counterproductive and will not prevent future repeats.
    IowaKaren likes this.
  2. 0
    What we do is we get the order, coumadin 5 mg po daily, next pt/inr is 12/7. So I will transcribe in the mar the new order and on 12/7 I will write vertically through the time slot INR. They can't sign anything out because the word INR is already written in the space. So when the new order comes in they highlight the old order and RE WRITE on another line the new order. Our labs are also written on the calendar. Lab send us a schedule of who they will draw at like 3 AM (auto system), the NOC nurse is to verify the sheet with our calendar.

    I hate coumadin!!
  3. 1
    Also, If I recieved an INR and I sent it to the doctor... I take the chart and put it on its spine in the chart rack. Why? Because everyone will say... why is that chart like that?, and I will say, I am waiting for coumadin orders.

    Have I said that I hate coumadin!!
    LTCangel likes this.
  4. 0
    PT/INR's have become a major headache where I work. We have 2 doctor's (husband & wife) who LOVE changing coumadin orders as often as possible. After labs we will get orders to hold coumadin for the day and re-draw labs in the AM. Or if they are on antibiotic treatments they order PT/INR's every other day. We have had resident revolt and refuse to let lab personnel draw their blood. I keep telling other nurses that it's a miracle that we don't have med errors regularly. I've seen residents have 3 or 4 dose changes in a week. It's crazy to be changing doses before we even get the med from our pharmacy!

    Just this week we had a doctor give orders for just 2 days worth of coumadin and then have them re-tested and then have to call the doctor back for the next 2 days worth of coumadin! So this resident was getting tested every other day and the nurse was having to put in new orders every other day. This went on for over a week. I couldn't believe it when I heard about it. Even the lab people who do our draws were wondering why they do SO many PT/INR's. Thank god im on night shift where I don't have to deal with that headache.
  5. 0
    At our facility, every resident on Coumadin has a weekly PT/INR unless a different schedule is ordered by the doctor. Every day before giving Coumadin, we are to check the latest PT/INR in the chart. By doing this, we can verify that the lab was drawn on schedule (our lab seems to drop people from the list periodically and then we have to order a stat lab) and verify that the order in the MAR is indeed the correct order. I think a flow sheet would be a good idea, but our biggest problem is the lab, not the nurses.
  6. 0
    System flaw. But, given that the procedure has been changed since the error, it sounds as if your being PI'ed is just something for them to include in the plan of correction. You are in a "See? We fixed it!" loop. Don't worry about it. Personally, I don't give coumadin unless I have checked the orders/labs, period. We've had huge errors with this med because there is so much room to drop the ball.
  7. 1
    Your DON said she'd report you to the BON for a med error? Yikes...I have high expectations for my staff but even I wouldn't call the BON for one med error.
    lindarn likes this.
  8. 0
    If you don't chart it, it didn't happen. When I pass something important off to the next nurse I chart it. "Will pass on to the oncoming LPN/RN" Don't beat yourself up. Something went wrong and the company has to blame someone so that when the state board comes to examine they can show they did something about it. I wouldn't let it get you down! You sound like a good and thorough nurse.


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