Is this a system flaw?

  1. 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.
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    Joined: Mar '11; Posts: 10; Likes: 3


  3. by   Esme12
    To me it looks like a system failure/flaw. I could barely follow your post but it seems that many nurses missed this order and the labs fell through on many shifts. Are there chart cheks done' and 24/hr checks? How often are the MAR's checked with the chart. What lab was it? If you don't mind me asking
  4. by   MonkeyLPN
    It was a PT/INR so it should have been checked the next day by someone that it was followed through, dr, nurse manager, even the nurse who drew the blood. But no one caught it until I did on Sunday. The nurse manager does not do a lot of chart checking unfortunately. Only when the DON is doing chart audits.
  5. by   psu_213
    I agree with Esme on several accounts. First, the grammar make situation post a little difficult to follow. Also, in general I would call this a system error. If a medication required labs TO BE drawn at a certain time, the doctor should write for the labs, the pharmacy should notify the floor that lab results must be available, and the nurse should be aware of this BEcause, if the labs are not drawn, harm to the pt could result (as for the CAPS, these illustrate 2 really big pet peeves of mine, so I had to point them out...sorry).

    As for not having PT/INR results...I am guessing that the drug in question is warfarin. In that case, perhaps the most recent INR should be charted when the medication is given. That way the nurse will (should?) question the date of the most recent INR, and, if it has been too long or if the INR was too high or low, they can call the provider to get an order for an INR to be drawn.
  6. by   mazy
    I also had trouble following the post but realized a few sentences in that this had to be a PT/INR because of how incredibly tightly regulated those protocols tend to be. Does your facility use a coumadin flow sheet? Those should be the first page on the patients MAR so that nurses can stay on top of that.

    It sounds like numerous people dropped the ball here and unfortunately they all landed in your lap.

    Usually my policy when working with patients on coumadin, especially if I don't work with them regularly, is to do a quick check first thing to find out when PT/INR was done and when it needs to be done next. A new admit on coumadin usually will be getting labs within the first few days of being admitted if not sooner.

    Also, make sure you find out from someone what Dr. protocols are for reporting PT/INRs. Some are OK if the results are faxed, as long as you check back at end of business day to get follow up orders; some prefer to have an actual conversation on the phone or in person as soon as the results come back; some do not want labs faxed at depends on the dr. Important thing is to get orders before you give the coumadin.

    Unfortunately as a nurse part of the job is being aware of the ways the system can fail and trying to stop on top of things so stuff doesn't fall through the cracks. As if we don't have enough to do!
  7. by   mindlor
    First let me say to the OP, please do not take this as an affront to you. However, at the end of the day, I could blame any mistake on the system. A perfect system could be put in place but it would be cost prohibitive. At some point human accountability must be a factor.

    Now, that being said, Japan is working on devloping robotic nurses...
  8. by   MonkeyLPN
    Sorry for the original post being a little crazy. I have a lot on my mind because of this situation. I think that putting the flow sheet would be a better way to go about having the PT/INR available to be seen. The flow sheet is in the pt's chart. So unfortunately it is out of site out of mind. Not that there is an excuse for this to have happened. As I was not the only nurse that had given this med to the patient, but as far as I know it is my fault. I will broach having the flow sheet added to the MAR and then having a copy in the chart.
    The way that this doctor returns labs is by the facility faxing the flow sheet with the lab results. Then the doctor will send back the order changes and the nurse on duty will fill out a T.O.
    Also I find it funny that the facility did not have me or anyone as far as I know fill out an incident report. In fact the patient was not even notified of the mistakes. It is like there were so many people at fault they didn't want to cause any extra issues. But I am the one that is being monitored now.
  9. by   psu_213
    Quote from MonkeyLPN
    I will broach having the flow sheet added to the MAR and then having a copy in the chart.
    I would think that the most important place to have it, to avoid missing INRs, would be in the MAR. As I said before, charting INR with each warfarin dose would not be a bad idea.
  10. by   LindsayRNer
    Quote from psu_213
    I would think that the most important place to have it, to avoid missing INRs, would be in the MAR. As I said before, charting INR with each warfarin dose would not be a bad idea.
    Love that idea, I don't have to deal with that much at all, just the initial INR.. or we could just use pradaxa. Sounds like a flaw in the system; there should be protocols to follow like a heparin flowsheet.
  11. by   LFalcon
    This is very interesting as something very similar happened in our facility recently. My floor in particualar has 3 res on coumadin, an outside company does lab draws. The coumadin draws are typically scheduled out... for ex: Resident A to take coumadin 2.5 x 14 days re check PT/INR level. So, dr is to be faxed and called. Usually if faxed dr never calls - so you must chase them down. (Monday I called 8 times). What is scary is the order ends -- so really you cannot give coumadin without a new order... you depend on that dr to call you. If they do not/you do not give it we were told by our DON it is a med error and she will report us to the BON. Last Friday I was off... someones orders ended Thur, no one called.. no PT/INR drawn Fri.. no coumadin given. Sat I worked, I saw it. Called the on call dr, chased them out of a christmas party asking what they would like to do..?? It was almost 8 before I gave the dose, I got the order for 2 days until Monday when it could be redrawn.. but honestly -- it scares me to death. The thought of being reported scares me and how easily it slips through the cracks... So this post makes me think... it goes on other places too... ???
  12. by   systoly
    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.
  13. by   PsychNurseWannaBe
    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!!
  14. by   PsychNurseWannaBe
    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!!

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