coumadin error

[medicarelpn]

I will try to make this as brief as possible but I would like to know what you all think. A friend of mine who works at a different long term care facility than I do called me at work yesterday and asked me to come over to her house when I got off of work, because she needed to talk to me. When I got to her house she was on the phone with her DON. When she got off the phone she told me a couple of weeks ago they had a resident that was admitted to her facility on Saturday evening, the nurse that did the admit (not my friend) wrote up her medication orders. This lady was 57 and had been in the hosp for MI, she had an order for coumadin but the order was not clear so she wrote pending on the order and it was supposed to be followed up on the next morning by calling the docter. This nurse also wrote on the med sheets Coumadin (pending). Well 4 days went by and no one followed up on the order. On the fourth day she was admitted to the hospital with a blood clot and died. Her DON wanted her and all the other nurses to write statements that pretty much stated that they were negligent, she told my friend that this would go no further than her and the administrator. The family is irate understandibly so, my friend was so upset that she may lose her liscense I didn't want to tell her that she was partially at fault as she along with the other nurses did not followup on this order. But I did suggest to her she not put anything in writing until she talks to a lawyer. What are your thoughts on this? What advice should I give her? :uhoh21:

[austin heart, BSN, RN]

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.

[VivaLasViejas, ASN, RN]

I've seen this sort of thing happen in LTC more times than I care to count.......lack of communication between shifts, between management nurses and floor nurses, between facility and doctor etc. is rampant, and unfortunately in this case it may have contributed to a resident's death. I've seen orders for high-alert medications that are illegible, misspelled, or just plain WRONG, and once patients are in the nursing home, it's all too often 'out of sight, out of mind' for a lot of docs, so it becomes difficult, if not impossible, to clarify those orders.

However---that Coumadin order should have been clarified by the very first licensed person to see it, and if nothing else the resident care manager should have been aware of the problem and taken care of it herself. When I was an RCM, I always had admission orders faxed to me before a resident even arrived on my unit, so I could call the MD and get any questions answered before the resident dropped off the physician's radar screen. I caught more than one potential error this way..........once, I had a resident come in with orders for what looked like 100 units of Lantus insulin at bedtime, an amount I thought excessive, so I called the physician. Turned out the order was for 10.0 units.......of course, the doc shouldn't have put that extra 0 there, but at the time I worked with a couple of nurses who WOULDN'T have called to question the order, and thus the resident might have received a tenfold overdose of insulin :stone

Granted, not every LTC facility is so lackadaisical about following up on questionable orders, and certainly no hospital is perfect either; but it's terrible that SOMEONE didn't take the initiative and follow up on that Coumadin order sooner. On the other hand, the nurses involved should NOT write letters admitting their culpability---that's just asking for trouble, and their DON is way out of line in trying to get them to do so. JMHO.

[mandykal, ADN, RN]

ERROR post

[mandykal, ADN, RN]

Although, At times reading this forum gets boring with many routine complaints, or everything that could, and had possibly happened in the field of nursing, let this thread remind us that when we continue our career in nursing, this field is no joke.

Always be alert to critical cases, anything that compromises the "ABC's" is always considered priority. We all know that. I do agree with other posters with many rationales. I can't say for sure that because of the patient did not receive continuous treatment of anticoagulant was the cause of her death, but you can answer the question; "what were the odds of her surviving had she been full treated?"

All I know is that at age 57, someone possibly lost a mother, grandmother, daughter, sister, aunt, cousin, friend & and it can happen to someone related to you. (and yes, it's forum like this that wakes me up from my boredness)

____________________________________________________________

Don't forget the nursing process

[leslie :-D]

On the other hand, the nurses involved should NOT write letters admitting their culpability---that's just asking for trouble, and their DON is way out of line in trying to get them to do so. JMHO.

but marla, you must agree that an incident report and med error report be initiated for all those involved. of course you never say i was negligent,but as i stated, you report the facts only, even if there are repercussions.

leslie

[Jo Dirt]

This is a prime example of why I hope I never have to be in a nursing home. You really can't blame the staff, because if it is like most LTC facilities, there is no way the amount of patients staff is expected to be responsible for is reasonable (where I come from one nurse is responsible for ALL the care of 40+ patients), and I can see how this could have been lost in the shuffle of the hectic day to day chores.

[pebbles, BSN, RN]

This is a prime example of why I hope I never have to be in a nursing home. You really can't blame the staff, because if it is like most LTC facilities, there is no way the amount of patients staff is expected to be responsible for is reasonable (where I come from one nurse is responsible for ALL the care of 40+ patients), and I can see how this could have been lost in the shuffle of the hectic day to day chores.

Hence the importance of incident reports, because they go to the admin to look at how the entire "system" is involved in the error. This was pretty darn scary, but the system of how meds are checked and ordered is at fault here, not just the nurses involved. The initial incident report should be enough, imo, not writing letters, etc. If the nurses are to be disciplined in some way, let the facility or BON initiate it, and the nurses respond. If the facility has a system that allows errors like this to slip by, why on earth shoulld the nurses write letters taking all responsibility on themselves?

This should be a wake-up call to all the nurses on staff as well as admin, though.

Re: coumadin - I work in acute care surgery. We have two pt's here who are never ever going home again. They are now on TPN forever, both of them developing clots that cut off supply to the bowel, causing ischemic gut and having to have most of their bowel removed. They were both off their coumadin for a couple of days in preparation for elective surgical procedures. Missing coumadin doses can be a very big deal.

[Tweety, BSN, RN]

but marla, you must agree that an incident report and med error report be initiated for all those involved. of course you never say i was negligent,but as i stated, you report the facts only, even if there are repercussions.

leslie

One incident report would suffice. An incident report is only to notify risk management/management of an incident, which obviously they are well aware of. Obviously more incident reports aren't going to hurt.

Often when there's a major event nurses are asked to give a written statement of the events. I've done this before. This is to have a written record so that if and when it goes to court years down the line, they don't have to put pieces of the puzzle together.

People just need to be honest. For instance if someone saw the order "pending" and ignored it, or presumed it was being handled by someone else, then they just need to say that.

Honesty and the facts, even if it makes the nurse and the facility look bad is the best policy here.

Hard lessons learned.

A facility worth anything will use this event to improve their obviously flawed system, rather than fry the nurses. Obviously though, if a nurse needs to be reprimanded or fired that should happen, but the facilities processes should be reviewed to prevent another event.

To the person stating coumadin has a long half-life. If the person's INR was therapeutic, or on the low side, four days is enough time for it to become subtherapeautic. No one will know whether or not it's because the patient didn't get the coumadin that caused the clot and death. But a judge and jury are more than likely going to side with the fact that it probably did.

[PJMommy]

Not sure if your question has been totally answered...

I would never, ever put anything in writing other than a totally objective, actual incident report. If this becomes a lawsuit, the facility will use these "statements" as a means to prove that their "system" was not faulty but instead that the nurses were negligent. They are covering their own butts at the expense of the nurses. In addition, all these "statements" are discoverable in a lawsuit whereas the incident reports are not usually. Not a bad idea to talk to a lawyer and, ideally, a nurse attorney who handles these types of situations.

[Daytonite, BSN, RN]

I would never, ever put anything in writing other than a totally objective, actual incident report. If this becomes a lawsuit, the facility will use these "statements" as a means to prove that their "system" was not faulty but instead that the nurses were negligent. They are covering their own butts at the expense of the nurses. In addition, all these "statements" are discoverable in a lawsuit whereas the incident reports are not usually. Not a bad idea to talk to a lawyer and, ideally, a nurse attorney who handles these types of situations.

I've got to tell you that incident reports are discoverable. If the other side of the lawsuit knows that any kind of documentation about an incident exists they can file a request with the judge to get copies of it. It doesn't always mean that they will get to see it, but it has happened that judges have allowed the incident reports to be discovered by the plaintiffs.

I would never write anything on a incident report that I didn't already have in my documentation in the patient's chart anyway. The only other information on an incident report would be statistical data used by the safety committee of the facility.

[Daytonite, BSN, RN]

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

No. People who are determined disabled by the social security administration are eligible for Medicare and Medicaid benefits. This would include people who have had catastrophic events that have left them unable to work steadily, or people who have chronic mental illness that has prevented them from continuing to work. If someone needs dialysis or is diagnosed with terminal cancer they can apply for and will most likely be made Medicare eligible through disability. Anyone who has a kidney transplant is automatically placed on Medicare for one year. The rules change from time to time and they can be confusing.

[Daytonite, BSN, RN]

I've seen this sort of thing happen in LTC more times than I care to count.......lack of communication between shifts, between management nurses and floor nurses, between facility and doctor etc. is rampant, and unfortunately in this case it may have contributed to a resident's death. I've seen orders for high-alert medications that are illegible, misspelled, or just plain WRONG, and once patients are in the nursing home, it's all too often 'out of sight, out of mind' for a lot of docs, so it becomes difficult, if not impossible, to clarify those orders.

However---that Coumadin order should have been clarified by the very first licensed person to see it, and if nothing else the resident care manager should have been aware of the problem and taken care of it herself. When I was an RCM, I always had admission orders faxed to me before a resident even arrived on my unit, so I could call the MD and get any questions answered before the resident dropped off the physician's radar screen. I caught more than one potential error this way. . .Granted, not every LTC facility is so lackadaisical about following up on questionable orders, and certainly no hospital is perfect either; but it's terrible that SOMEONE didn't take the initiative and follow up on that Coumadin order sooner. On the other hand, the nurses involved should NOT write letters admitting their culpability---that's just asking for trouble, and their DON is way out of line in trying to get them to do so. JMHO.

I would have loved to work with you! The facilities I worked in did the same thing. We knew and had clarified the admission orders before the patient even set foot in the facility. Any questions we had went right back to the doctor or the discharge co-ordinator at the hospital. Those admission charts were given special scrutinization.

I also just wanted to say that the DONs in some of these nursing homes are just RNs like any other RNs. Some of them get their position by luck, because no one else was around to take the job. They take the position because they've always wanted to be in a managing position. When an incident like this comes up it's their initiation by fire into the complex world of management. Nursing homes have very special problems and are more regulated by law than any other healthcare facilities. It's become that way for just this kind of incident happening again and again. Since the nursing homes won't police themselves and clean up these messes, the legislators have had to step in and do it.

Unless the patient's family insists on something being done, this thing is probably going nowhere. Nurses hands will get slapped (or whatever the facility decides to do). Unless a direct cause linking this patient's death with not receiving this medication can be proven any court case will probably go nowhere. I'll bet there are other medical problems this patient had that most likely contributed to what happened as well. This family is going to be lucky if they can get a settlement that will pay the patient's medical expenses (that is, assuming they sue). Isn't that sad?