didn't call about anticoagulation

Lev, MSN, RN, NP · Mar 27, 2016

At the end of the day it is the doctor's responsibility to start a patient on a med. We can make suggestions as nurses but we are not prescribers. Don't beat yourself up about this. This is a doctor to doctor communication that needed to happen. The GI doctor should have left a note that addressed the anti-coagulation.

bebbercorn · Mar 27, 2016

I am so sorry for your rough day!!! From ED perspective (and I don't think this is necessarily right), generally the admitting MD orders it, and it is started on an inpatient basis. Unless, the admitting MD asks the ED to start it, or the patient holds in the ED. Then we can access inpatient orders.

You had a day from hell and made it. You would have well been within your rights to give some of that attitude right back for calling you at 11 pm! Years in, I still make mistakes. Of course, I internally beat myself up, but externally, thank God, I have reached the point where I can just say "Yes, you're right. I should have done XYZ. Good catch. So, how's the gardening going?"

kidsmom002 · Mar 27, 2016

I'm sorry you had such a bad day. Personally, my opinion is that when floating to an area you are inexperienced in the staff on that floor needs to be understanding of the fact that things may get missed or not done to their "standards". Don't get me wrong, we should give the best care possible in a safe manner. That being said, it is unreasonable to expect someone with no experience on a unit to know every possible action that is expected. To me, when someone floats, they are basically there to keep the patients alive until the next shift arrives. I see it as providing a very basic level of care. You cannot expect a float without experience on the unit to provide the same level of care as staff experienced on the unit are able to give.

To call you at home to ask why you didn't call the doctor to ask for an order was unreasonable and rude on the part of the staff nurse. She could have just made the call herself. It's not as though she was calling to see why you failed to administer a medication that had been ordered. If it was me I would have assumed you were unaware that was a standard on that unit to call for the order and would have just done it myself. When I've been floated and received attitude from the staff I always remind them that the patients are all still alive and they can complete anything I was unaware needed to be done. I feel no guilt since if I wasn't there the staff would have needed to absorb my patient load as well and likely even less would have been accomplished.

SarahJ08 · Mar 30, 2016

The nurse should have addressed this with you while you were giving report, they were way out of line to call you after report and clocked out. I would have been livid to receive a call like that, that late a night and would have told the nurse that she has wasted her time calling me and that her questions needs to be taken up with the md as to why the patient wasn't started on heparin if she's that concerned about it.

kaylee. · Mar 30, 2016

So initially heparin order was deferred to GI to r/o possibility of bleed. At 3 pm this was the status you were given. I'll bet some doctor called the floor at 11 pm yelling at the nurses asking why heparin was not started. So they impulsively called you to shift the blame off of them! I feel like some docs do this to pass the buck a little, and since they are not calling their fellow docs and yelling, guess who takes the heat? Us. If you passed this situation on in report, then the night nurse had every opportunity to see this as a priority and take action and get the order for heparin, but they didnt address it either. In the 4 hour window you had the patient there is only so much that one nurse can do. The night nurse also let 4 hours pass without putting a call out.

Totally rude for them to call you like this!! Things get missed, but how is calling out you going to help the patient?? Shake this one off, you did the best you could. Don't worry about getting fired, and especially don't worry about your license!! This was just one of those pass the blame BS issues. As someone else mentioned, its not like you failed to initiate an order!

canigraduate · Apr 1, 2016

I wouldn't float to that unit any more, if I were you. Sounds like they used and abused you. However, you did screw up.

With you being a new grad and this being your first float, you should have asked the charge nurse and the other floor nurses for help. Write down door codes somewhere on your SBARs/brain sheets. You can usually call pharmacy to get added to the med cart. On a unit like that, the aids should be getting accuchecks.

Anyway, it was pretty crappy of them to call you about the heparin that late at night. What were you going to do about it at home?

However, forgetting to ask GI about anticoagulation in a bilateral PE patient is a pretty big deal. There may be some fall out from that.

The admitting doctor usually writes for anticoagulation, not the ED doc. The ED's purpose is to stabilize and turf. So, even though the patient was in the ED since 6 am, it was not their responsibility to take care of getting an inpatient order.

I'm sorry, but this was a big mistake that caused a potentially harmful delay in patient care. The other things you mentioned were overwhelming, yes, but you have to know your priorities. Accuchecks and meds can wait when your patient has a potentially fatal issue.

Don't beat yourself up about this, but definitely learn from it. You need to talk to your manager about what happened and acknowledge your mistake. You also need to formulate a plan so that when you get floated again, you know what to do to get oriented and functional on that unit. It is a fact of life that you will be floated again, and you need to figure out how to deal with it.

I'm sorry this happened to you. I hope you can learn and move on from it.

calivianya, BSN, RN · Apr 3, 2016

Unless you had proof that there were other DVTs hanging out in the legs or wherever ready to become new PEs at a moment's notice, the patient can afford to wait a little bit to have anticoagulation addressed. PEs are going to kill you when they first hit if they are going to kill you. Someone who throws a saddle PE is going to die pretty much immediately. If the patient has PEs, is NOT DEAD, and the venous dopplers are negative for more clots - the most immediate danger has passed. You mentioned the patient yelling about being NPO, so it sounds like the patient is just fine to me. There's no way someone with a bad PE could yell - they'd be way too short of breath.

Does the patient need anticoagulation? Yeah, sure. The PEs do need to be broken up eventually. However, I would be willing to bet the GI docs would have said no to heparin at the moment even if you had remembered to ask. If the hemoccult is positive the patient likely has a current bleed, and anticoagulating a bleed is way more dangerous than not giving anticoagulants to a stable PE patient who is well enough to yell over NPO orders.

You didn't screw up that badly. I would say something to that unit's supervisor about the nurse who called you at home to complain at you - that is very inappropriate behavior, and that nurse needs to be spoken to.

canigraduate · Apr 4, 2016

Unless you had proof that there were other DVTs hanging out in the legs or wherever ready to become new PEs at a moment's notice, the patient can afford to wait a little bit to have anticoagulation addressed. PEs are going to kill you when they first hit if they are going to kill you. Someone who throws a saddle PE is going to die pretty much immediately. If the patient has PEs, is NOT DEAD, and the venous dopplers are negative for more clots - the most immediate danger has passed. You mentioned the patient yelling about being NPO, so it sounds like the patient is just fine to me. There's no way someone with a bad PE could yell - they'd be way too short of breath.
Does the patient need anticoagulation? Yeah, sure. The PEs do need to be broken up eventually. However, I would be willing to bet the GI docs would have said no to heparin at the moment even if you had remembered to ask. If the hemoccult is positive the patient likely has a current bleed, and anticoagulating a bleed is way more dangerous than not giving anticoagulants to a stable PE patient who is well enough to yell over NPO orders.
You didn't screw up that badly. I would say something to that unit's supervisor about the nurse who called you at home to complain at you - that is very inappropriate behavior, and that nurse needs to be spoken to.

I know you are in a critical care role, which colors your perceptions. If it isn't going to kill your patient RIGHT NOW, then it isn't as important to you. Critical care also has a lot more autonomy and less micromanagement.

In the role of a floor nurse, not following up on anticoagulation is a big deal. It's also a breakdown in nursing priorities and critical thinking when you call the GI doc twice for a diet order but don't bring up the anticoagulation once.

In most of the hospitals I have worked, this is an automatic incident report. In some of the more punitive ones, the OP would get a talking to and maybe even get corrective action.

I'm not saying this is on the same level as an insulin mistake or something. I also think it's stupid that the nurse deals with this and not the attending. But, things would make more sense in general if I ran the world, LOL!

I agree, it was beyond ridiculous that the OP was called at home that late at night.

I hope the OP doesn't get in trouble and that she learns from this.

Cowboyardee · Apr 7, 2016

Here's the good news: I very much doubt you're going to get in any serious trouble over this. For one, the people who got worked up about it aren't responsible for disciplining you. The night nurses on another unit, perhaps an intensivist or hospitalist - you don't work directly for them. If anyone decides to write up an incident report or, worst case scenario (which isn't likely for a small, stable PE), something bad happens to the patient and this gets sent to the higher ups, risk management is not likely to see getting anticoagulation ordered as primarily your responsibility. That's a doctor's responsibility, and the intensivist probably should have spoken to GI directly.

You might get a talking to from one of your managers or your educator. Thank them for setting you straight, and that should be about it in terms of consequences.

The bad news: this situation is decent illustration of some of the problems you'll see over and over again in nursing in most institutions. Some points, below.

- Bad days happen. I don't mean to downplay your feelings here. I'm just stating it as a simple fact. They can feel awful, especially when you're newish and haven't been through the ringer a few times. But they happen, and they'll happen again. You're a little bit more experienced and wiser now for it. Use this as a learning experience.

- You're expected to do the job competently whether or not you're getting adequate resources or support from the unit you're on. Floating can be dangerous for this reason. If the staff on another unit aren't giving you the information orientation you need, you need to be pretty upfront about asking for it. Ask for the door codes, a quick tour of the unit, and a rundown of things you need to know right at the beginning of a shift on a new unit.

- You'll find that much of the time hospital staff hangs each other out to dry, it's staff from one unit or department hanging staff from another unit or department. Incident reports are more likely to be written when it involves staff from another department than when it involves immediate and well-acquainted coworkers. Know when you really need to cover your butt.

- I said above that risk management will not likely consider it primarily your responsibility to get orders for the patient's primary plan of care. This is true. But functionally speaking, it still often winds up being your job. Fact of the matter is that doctors are often spread too thin to fully manage a patient's care in the hospital. Some of this then falls to you as a staff nurse. The biggest reason for you to be on top of the patient's plan of care isn't concern for your own license, but because your patients and the system we work in need you to.

Newer nurses often tend to think of their daily duties as a kind of list of things to get done. This is what they focus on, the list. You may have heard people call 'this task-centered thinking.' Experienced nurses tend to think in terms of some goal for the patient - the primary goals of care - and prioritize their tasks around these goals. You're new and your thinking is understandable. But, again, use this as a learning experience, and try not to lose the forest for the trees as you gain more experience.

sweetstrwbrry1 · Apr 7, 2016

Update:

I never heard anything more from this unit or about this situation from that unit or my own. I had come into work and was floated to that unit not by choice just for that day. I honestly hope I never float again. The responsibilities and being in an unfamiliar environment were overwhelming. On my floor we only have 3 patients and they are mostly post-op. This floor you have 4 patients and they can be total care and with all sorts of issues that I am not familiar with from my unit. They also get a lot of direct admits from the ED which I had never done before. And on top of that having no support, having no access to stuff to do my job, and no idea where anything is. I'm also not used to patients screaming at me about stuff. I swear we must have a different patient population on my floor because we don't get patients like that.

I called in the next day and was able to regroup myself. If I had actually not been thrown under a bus with no support I think I would have had clearer judgement about what to do. I agree that floating is dangerous. I could never be a float nurse, I know people who do that all the time. I feel comfortable on my unit & could not be happier. There would never be a time where the stress would affect my ability to do my job. I'm actually very grateful for my unit because now I know how good I have it. I do have difficult days but I don't think anything compared to like this unit I floated to. I give those nurses a lot of credit, honestly I don't think I would still be in nursing if I was originally assigned to work there. :/

**canoehead, BSN, RN** · Apr 14, 2016

At our hospital we can float and state we are there to do tasks only. It's unreasonable to take on a full assignment without an orientation. Impossible to get things done in a timely manner if you don't have codes or access to the medication carts. It would have been nice for you to mention the anticoagulation, but ultimately it's the doctors' decision. They were all aware of the need, and apparently hadn't gotten a chance to put their heads together.

And that nurse...she knew you didn't get out of there til 8pm, that you were a float with a really tough shift. She didn't pick up on the anticoagulation order until 11p. She's just trying to pass her inattention on to you.