Is this a system flaw?

[MonkeyLPN]

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 pt 2 days into the stay. Usually on the MAR directly below the med that needs labs drawn will be a date that a lab is drawn and initialed when it was drawn, and also usually there is only 1 person writing dr orders, on this day there was an orientee, a student, nurse manager, and the day nurse, so it was a madhouse that day I do remember. I don't remember receiving any indication that this particular pt had labs drawn on this certain date and I ordered more meds from Pharm, which they sent, which usually they will not do if labs need drawn. FF to Sunday I was looking in the pt chart and found that there were labs that were drawn and that the dr had not signed them. So I took out the labs and asked the oncoming nurse to see what happened cause from what I could figure out is that the day nurse from the day the labs were drawn did not fax the doc the results so there were no dr orders.

I know I dropped the ball that day the labs were drawn, I should have been more careful. But I feel like in this particular case even a nurse working there a long time would not have caught this. I do feel like a failure, but I am glad that I also caught this mistake. I am currently having to complete a month of "performance improvement." Which means my nurse manager has to look into my work a little closer and make sure I don't screw up again. Which she admitted that she should have been more specific on the mar in the 1st place and that she doesn't think that this is something that would happen again with me. The facility I am at has also changed the way the MAR will be written out and have more checks and balances especially for meds that require blood draws.

I keep trying to remember this particular day as the day nurse SWEARS she told me about the labs, yet did not chart anything about the labs being sent to the dr, which she usually will write at the bottom of the page when she faxed etc. Also the labs were put in the chart without being signed. I would NEVER do that, so who did? Usually the labs stay out of the chart so we know that the doctor has not sent back a signed order, so not to give the med. Also why wasn't this caught by someone, pharmacy, nurse manager, the day nurse? I am PRN nurse and I feel like sometimes I am the scapegoat when things go wrong, although I will accept responsibility for this mistake as I ordered the meds and did not see the labs.

[PsychNurseWannaBe, BSN, RN]

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!!

[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.

[Kittypower123, BSN, RN]

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.

[SuesquatchRN, BSN, RN]

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.

[CapeCodMermaid, RN]

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.

[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.