coumadin error

i believe she has to write an incident report anyway....that's just a part of any p&p.

did your friend say why she did not call the md to verify orders?

on any new admit, we always had to verify the meds.

sorry, but coumadin is one drug that you don't write 'pending' esp w/a dx of an mi.

i'm hoping she takes responsibility on her end of it.

i wish her well.

leslie

i believe she has to write an incident report anyway....that's just a part of any p&p.

did your friend say why she did not call the md to verify orders?

on any new admit, we always had to verify the meds.

sorry, but coumadin is one drug that you don't write 'pending' esp w/a dx of an mi.

i'm hoping she takes responsibility on her end of it.

i wish her well.

leslie

I agree. The MD should have been paged to verify the order and an incident report should have been completed.

With the diagnosis of MI and on Coumadin and a hard to read order for it, I would immediately call or page the doctor and make sure that he took care of that order then. Coumadin is not something that you mess around with. I would have never left that order waiting for someone else to call the doctor in the morning...And if the doctor gives you a bad time then he is an *** also....

While this is a serious med error. I question if this caused her death. Coumadin has a very long half life.I have had surgical patient's in the hospital 2 weeks just waiting for their blood Ptotime to come down to a level safe for surgery. If the patient was at a theraputic level when she was discharged I question if he protime would come down that quickly.

While this is a serious med error. I question if this caused her death. Coumadin has a very long half life.I have had surgical patient's in the hospital 2 weeks just waiting for their blood Ptotime to come down to a level safe for surgery. If the patient was at a theraputic level when she was discharged I question if he protime would come down that quickly.

i don't think that's really the point here.

whether her pt/inr levels were in therapeutic range is irrelevant to the handling of the admission.

chances are she was a medicare pt to receive various skilled services. yet ot or pt wouldn't even look at her meds.

and yes, it was erroneous of all the other nurses that did not question the coumadin orders.

but the bottom line is whoever did the admission, was responsible for verifying meds. and coumadin is a drug that you do not wait til the next day. we're not talking about colace here.

and i've seen pt/inr's drop to sub-therapeutic levels in a few short days.

but the nurse who did the admission needs to fill out an incident report, stating the facts and only the facts.

leslie

Don't you have to be 65 to be on medicare?

Don't you have to be 65 to be on medicare?

If they are on disability they can be under 65. We have had only a few resident under 65 and they are usually short stays.

Thank you.

This did not happen at my facility it was a facility my friend works at. At the facililty I work at we have double and triple check systems to keep this kind of thing from happening. I do not know if an incident report was filed or not as I do not work at the facility I do not have all the specific details. Myself though if I'm am giving meds, when I look at the med sheets If we do not have a med or I feel there is a question about the med I immediately get into the person's chart to try and find the original order, then check with the pharmacy If I still have questions I call the MD.

While this is a serious med error. I question if this caused her death. Coumadin has a very long half life.I have had surgical patient's in the hospital 2 weeks just waiting for their blood Ptotime to come down to a level safe for surgery. If the patient was at a theraputic level when she was discharged I question if he protime would come down that quickly.

I am not saying that the lack of coumadin was the cause of this patients death but......The half life of coumadin is approximately 42 hours but varies widely depending on the individual. Most patients therapeutic range is also very narrow depending on what the diagnosis for the coumadin is. I am assuming that the patient also had a diagnosis of clotting disorder, mechanical valve, A-fib, etc as coumadin is not a standard order for typical post MI as OP stated patient had been hospitalized for. I would also think that the patient was under coagulated if they developed a death causing clot. 4 days is plenty of time to become sub-therapeutic.

I also do not think that blame falls solely on this one person's shoulders. It looks like there could be any where from 8 to 32 nurse caring for this person in four days depending on 8 or 12 shifts and if the same nurse cared for the person more than once. It is hard to understand why any one of those nurses could not pick up the phone and make a simple call to the MD. I think that a hefty part of the blame falls at the feet of the admitting nurse, she should have been the one to clarify the med order. I am assuming that the patient came in during the day time, not many hospital-nursing home transfers in the middle of the night, so some one should have been able to get in touch with an MD during reasonable MD hours even on a weekend. In any case a med error occurence report needs to be done reflecting all nurses that cared for this patient.