Heparin IV Error? So Upset and Scared

  1. Hi everyone, I'm a new grad nurse and have been off orientation for about 2 months now. Today one of my patients were to be put on a heparin drip. The doctor asked me for the order form and then did not fill in the information, so I sat in the chair next to her and provided her with the information for the patient in the "Bed 1" which she had asked for. I had given her the weight of the patient and she still didn't fill out the form correctly. So I asked another senior nurse to help me approach the doctor to clarify the order because it didn't seem like she knew how to order it correctly. The patient label was on the order form and once the order was clarified she signed the order. I thought it was a little bizarre for the patient to be getting put on heparin but my patient had a hcof Afib so it made sense to me and the senior nurse. We went back to the doctor three times before the order was clarified and we even had to call the pharmacy to make sure that she ordered it correctly per hospital policy. Turns out she told me the wrong bed and the heparin was to be for BED 2 NOT BED 1. It was about 45 minutes after I infused the heparin I realized the error because I went through the new orders put in for the afternoon and saw she wanted a Coumadin ordered for tonight and heparin to be d/c'd in the nursing communications. I checked both my patients labs and realized the mistake that was made and my heart dropped. I thought immediately how stupid I was for making this mistake and why I didn't recognize it sooner. I don't know why I thought the order was okay when something was telling me no, but because I'm new I figured maybe I was over thinking it. When I noticed my mistake i immediately stopped it and just ordered a STAT ptt per nursing judgment and checked vitals the patient was stable and the MD was notified but because it was Christmas even she didn't respond for almost an hour! I continued to monitor my patient. I told the charge nurse and the nurse that originally Consigned my heparin and they both were shocked because the doctor did infact sign the order for patient in bed 1, so technically I didn't make an error, however an error was made because it was given or ordered to the wrong patient. Her labs came back normal and I sent the doctor a message and voicemail. She eventually got back to me and said that it was okay, and that the patient was alright and not to worry. I told her what happened and that the wrong sticker and info was given because I believed that she was talking about bed 1 and not 2. However I should have known better and I can't stop beating myself up. I feel stupid and like I shouldn't be a nurse anymore. I know it only infused for a whole 45 minutes but still that could have been bad! The charge nurse told me I should be proud of myself for realizing and questioning the order for that long because she said she would have just assumed the doctor changed there mind. I still feel like I'm an idiot and I should've caught on to the issue. Both the patients were on Coumadin and we're suppose to be discharged and the doctor was talking about them by bed number and not name! So it confused me and an error happened. I can't forgive myself and it shook me up so badly all day I could barely show my face around my charge nurse and consigning nurse because I was so ashamed of myself. They reassured me it was the MD who was at fault because ultimately it was there fault for signing an order with the wrong patient info, and they are responsible or filling it out and then scanning it.. which is to prevent errors like this. I also really like this doctor and I don't want her to think I'm a idiot but I really feel like one. I'm scared I will be written up and fired. I wrote an incident report and wrote up every detail in my shift notes. I also throughly explained the situation to the night shift although embarrassing to protect the patient from further harm. The Coumadin order that was placed by the doctor on the computer for 2100 also confused me and the charge nurse and when night shift was told about the Coumadin order they too thought it was bizarre and the order for both the heparin and Coumadin was not necessary, the night nurse who precpeted me for a little bit told me it was okay and that I did the right thing and I did no harm. I just feel SO HORRIBLE And ashamed, I know I should email management as well in the morning and just confess to protect myself and own up to my hideous med error.

    Im not sure how to feel, I don't want the doctor to hate me or think I'm stupid or my fellow nurses to think I'm incapable. People tell me I'm a good nurse and I perform well and now I don't want people to look own on me. What should I do?
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    About MayaRN123

    Joined: Dec '17; Posts: 1

    3 Comments

  3. by   tree-huggin'RN
    Hey there and merry Christmas!
    Cut yourself some slack. I'm a new grad too. Off orientation for about two months. You caught yourself! That's FANTASTIC work! Sometimes these things don't get recognized until much later. I've made some mistakes too. No one was hurt. You gotta pick yourself up and demand to move on. Learn from it. Next time, clarify "was that so and so in bed 2 that you ordered that on?"
    Use the first, last, and DOB.
    You got this! You're obviously doing great. Wipe off the dust and move on.
  4. by   Nursewifemom
    You clarified with the Dr. You clarified with pharmacy. The Dr. Is responsible for filling out the order on the right pt. You saod You filled out an incident report. That should cover it. That is designed to help evaluate where problems exist so they can be addressed. With a hx of afib I can see where you thought it was ok. Dont beat yourself up about it. I'm sure you are a fantastic nurse. Side note: in our facility pharmacy wont put on a heparin order With out a ptt already on file for the pt.
  5. by   Julius Seizure
    Goodness gracious my dear, it's okay! You are being really hard on yourself. Listen to the nurses around you - the charge nurse, the nurse who co-signed the order, your former preceptor....they are all telling you that its okay! Listen to them! Yes, it was an error (primarily the MD's error), but you caught it, and you did exactly what you should have done - you reported it to the MD, you stopped the infusion, and you wrote an incident report.

    Now let go of it.

    It's really okay. Really.

    Nobody - not the MD or the other nurses - thinks that you are an idiot. They just think you are a human. It literally could have happened to any of them.

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