Is this a system flaw? - page 2

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... Read More

  1. by   usafguy99
    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.
  2. by   Kittypower123
    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.
  3. by   SuesquatchRN
    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.
  4. by   CapeCodMermaid
    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.
  5. by   LellyNurse
    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.