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Do you think I did something wrong here? Advice?

ellebee87 ellebee87 (New) New

I hope this is the right place to put this.

I'm a CNA/Med Tech in an alzheimer's unit. I'm also a nursing student- I'm about halfway through my RN program. After the events of Saturday night I'm very worried about my job, and potentially my license.

Our unit still uses paper MAR's. On Saturday evening when I went to pull meds for a resident, I noticed that he had two separate orders for Warfarin. One was for 7mg, which had started five days prior, and one was for 5mg, which had been held but then resumed. They were both initialed every day for the last five days. I was concerned, and took it to the nurses on the skilled nursing unit. The nurse on the skilled unit and I looked at his orders, and the nurse in skilled nursing determined that an error had been made. She called the on-call doctor, who DC'd the 5mg order, and I was told to write a statement of what had happened for the DON and put it under her door. The resident was fine, his vitals were fine, and he was alert, so I left it on the 24 hour report and went home.

I got a text this morning from a fellow CNA to "warn" me that the unit coordinator, who is also a med tech, is very upset with me. When I asked why that is, she claimed that I should not have had the 5mg DC'd, and that I shouldn't have called the on-call doctor, because he uses an outside doctor. She also said that everyone else knew to only give him the 7.5 mg...but the order for the 5mg was being signed off on as well. I only work weekends, so I had no way of knowing that's what everyone was doing, and even if I had, I'm not comfortable signing off on something I didn't give.

I'm terrified to go back to work on Friday. I called the DON and left a message asking her to call me back, and I plan on asking her if I did anything wrong, but I'm extremely anxious and wracking my brain to try to figure out if there's anything I could have done differently. I guess I could have noticed that the nurse was calling the wrong doctor, but frankly I was a little panicky that 12mg of warfarin had been given instead of 7mg for over five days.

Is there anything you would have done differently in this situation? I don't want to get this attitude in my mind that I know better than the other girls because of nursing school, but I'm very upset that this happened at all, and also very upset that I'm hearing from other co-workers that the coordinator is upset with me. I feel like if I did do something wrong, that should be between myself, the DON, and the unit coordinator. Do you think there's anything that I could say or do to fix the situation?

I think you did the right thing. I don't quite understand what your scope of practice is as a Med Tech, but the only thing you did was bring it to the attention of the nurse, who then took it upon themselves to get the order clarified and the extra dose discontinued. Better to error on the side of caution. I wouldn't stress, you did the right thing and sound like you are on your way to becoming a safe, conscientious nurse.

Thank you for the reassurance. As a med tech I am allowed to pass medicines that the residents can self administer- just oral drugs, basically. Also insulin. Frankly I don't really think it's a good idea to allow CNA's to pass medicine because of situations like this, though.

Having two orders for Coumadin but not administering one is a med error waiting to happen. Are you sure the the other med tech wasn't making a med error for several days in a row and she is trying to wiggle out of this? Did the doctor order a INR? The MAR should be clear as to what is suppose to be given and what is not. Why hadn't the other people signed it off as "not given"? If I had two Coumadin orders in at my job in acute care and no other order to say the total daily dose is 12.5mg( which would be a high dose to give several days in a row) I'd want one discontinued. Kudos to you for looking out for the safety of the patient!

BuckyBadgerRN, ASN, RN

Has 4 years experience. Specializes in HH, Peds, Rehab, Clinical.

It sounds like very poor practice to even have BOTH doses available if the order had been changed. I'd say you did the right thing, absolutely by going to a licensed nurse for clarification. I doubt your "license" is on the line, because A) it doesn't sound like you did anything wrong and B), do you even have a license?

No, I do not have a license, but I do have a certification. I should have said certification. I'm also concerned about the RN license I will be applying for in six months when I graduate.

I'd keep this situation in mind in case you need an example of how you are an advocate for patient safety. You might need this example for a future interview when you become an RN. Remember what you did was a good thing!

The other med tech might be mad at you but that is his or her issue.

Be very proud. You where alert over a concern of two orders for the same medication in the computer. You did not ignore it and brought it to the attention of a nurse. She is the one that made a determination their was an error in the computer. Never 2nd guess yourself, and you didn't.

If this unit coordinator is upset with you maybe just maybe this error fell upon them. As far as them using a outside Physician, they should be counting their blessings that the family of this resident aren't suing. Then instead of just a outside physician their would be a big additional cost of a outside attorney and the litigation to the resident family.

Edited by Lisa.fnp

You did the right thing. Very wise of you to question an order, and to take your concerns to the nurse. Just curious -- as a tech would you be able to clarify the warfarin order with the MD? At any rate I applaud you for using good judgement.

iluvivt, BSN, RN

Has 32 years experience. Specializes in Infusion Nursing, Home Health Infusion.

I also concur that you did nothing wrong.The order should be clear: Adminster x mg of the drug at x time. None of this ambiguous crap that we all knew not to give the 5 mg, but we left it as an active order.The chart is a legal document and accuracy is crucial and it also serves as a critical communication tool. Do not be terrified to go back to work because you did nothing wrong.You questioned an order,brought it to the attention of the RN who clarified it with the practitioner

NotAllWhoWandeRN, ASN, RN

Has 8 years experience.

I'd keep this situation in mind in case you need an example of how you are an advocate for patient safety. You might need this example for a future interview when you become an RN. Remember what you did was a good thing!

Bingo. You looked at the orders, thought "This doesn't seem right," and you did something about it. Critical thinking and and advocacy make for a great nurse.

NurseSpeedy, ADN, LPN, RN

Has 18 years experience.

You did the right thing. You brought your concerns about the medication issue to the nurse. It was the nurse that contacted a different doctor (I've seen charts where the face sheet doesn't have the most current attending. She should have called the ordering physician but it wouldn't be the first time the wrong doc was called accidentally) but avoided continually dosing the patient with 5 extra mg of Coumadin daily. I'm more worried about the patient's risk for bleeding (possibly internal) and would also want an order for an INR since the patient appears to have gotten a heck of a lot more than intended (although someone is saying that they are all documenting it as given but holding it? I'm not going there. You can probably guess the problems I have with that loaded rationale you were given by your co-worker).

The situation stinks and my guess is that the ticked off coordinator is feeling some heat for this one. You bringing it into the light made it hard for her to possibly keep the issue quiet (Which is NOT the way to handle things but given the most recent history of events...). You saw a safety concern and acted upon it.

Conqueror+, BSN, RN

Has 26 years experience.

Don't worry and when you go to work please don't start asking around to see who is mad etc...Just go in and do your job as if nothing has happened.


Specializes in Oncology, Rehab, Public Health, Med Surg.

Good job, OP! You were really watching out for your patient!


Specializes in LTC.

Well done! You have the makings of an excellent nurse, keep it up! You are in NO danger of losing a license you have not obtained yet. NO CHANCE! Don't you sweat that. This situation was a mess and you did the right thing. I would have liked the doc to order an INR, immediately if you have the hand held unit or ASAP via the lab, just to be safe. Otherwise....

Your Unit Coordinator dropped the ball here on several levels...

1.) Why was it not CLEARLY evident on the chart that this patient had a unique Warfarin set up?

2.) The units paper MAR was INCORRECT.

3.) WHO does she think she is telling your co-workers that she is upset with you?!?! That is so unprofessional! She should be written up for her errors.

Please lose no sleep over this and frankly, I would have a REAL talk with the DON, if she calls you back, that you do not appreciate how this was handled and what second checks can the Unit Coordinator put in place so that you do not find yourself in this situation again, where you have to double check her work because patients are at risk.


Chaya, ASN, RN

Has 15 years experience. Specializes in Rehab, Med Surg, Home Care.

"If it wasn't written down, it wasn't done". (I'm guessing you've heard this a time or two). I don't know about your nursing curriculum, but mine did not include psychic divination of patient care delivered on previous shifts but not recorded. You had no way to know what doses were actually given; plus to further complicate the issue, future doses of warfarin would be based on how well the assumedly correct dose regulated coagulation. Even if you had been able to verify that the actual dose being given differed from the recorded dose, this is a med discrepancy and your only safe option was the one you chose, to present the situation with as much info as you could obtain to the covering MD for evaluation (not in your scope of practice as an RN.

Chaya, ASN, RN

Has 15 years experience. Specializes in Rehab, Med Surg, Home Care.

"If it wasn't written down, it wasn't done." You can't be expected to read minds re: what previous doses were actually given but not recorded accurately (not to mention how future doses of warfarin are based on knowing accurately what dose received caused a given response). If you have a med discrepancy the only safe option is the one you chose; notify the MD for any change in the order since prescribing is NOT in your scope of practice.

Here.I.Stand, BSN, RN

Has 16 years experience. Specializes in SICU, trauma, neuro.

You absolutely did the right thing! Having a MAR that has an old Coumadin order left active is a hemorrhagic stroke waiting to happen...because no, not everyone is going to assume that that one dose shouldn't be given. Not that they should have to assume -- MARs are supposed to be crystal clear. And then the fact that the MD did d/c the old order confirms that he should not have gotten those doses, so shouldn't have been on the MAR...let alone signed off as given.

Good job!

Bingo. You looked at the orders, thought "This doesn't seem right," and you did something about it. Critical thinking and and advocacy make for a great nurse.

AND when this patient bleeds out or has an INR of some astronomical number from receiving 12mg of Coumadin for 5 days, I would not want to be the licensed nurse responsible for the UAP's who gave this dose for days on end....

AND because one signs it, it is "given" therefore, it is false documentation if one is signing off on meds they are not given. And "the unit coordinator told me to" is not a valid argument.

You brought it to the nurse, the nurse got the order clarified, and now the follow up begins...which the mechanism of action of Coumadin is 48 hours or so.....what did we get for an INR?

In any event, you did the correct thing. The unit coordinator (and is this person a nurse, or another UAP?) can be as mad as they would like to be, however, you can not explain away 12mg of Coumadin. For 5 days. Or signing off on meds that you don't give that could cause patient harm. 7mg for a few days to get therapeutic is about as high as I recall ever going. You did the right thing. And the licensed nurse who is responsible for your work thanks you I am sure.


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