Drug error

[coneartist]

I was rushed off my feet and had an admission with ischaemic stroke. I asked the DR if he wants patient to have 300mg Aspirin STAT, he said no patient on warfarin and prescribes it, have that instead. I stupidly went and gave 6mg warfarin, turns out INR is 5.5. Im handing over to night staff and he put a STAT vitamin K 5mg PO order and didnt even bother to tell me.

I'm really sick of nursing sometimes, why is everything blamed on the nurse?????

How serious is this I'm a new nurse..

[~Mi Vida Loca~RN, ASN, RN]

Unfortunately, it is a big deal to give a blood thinner when the blood is already too thin. I know that it seems that everything is the nurses fault but that's because we are so smart and important that everyone depends on us to do it right.....at least it's what I tell myself. He should have checked or at least asked what the INR was but you should have checked before you gave it. It should be just fine and it takes time to get all your ducks in a row to know what to do, ask and look for. Lesson learned, don't make the same mistake twice and move forward. I know that with MD order entry it is a pain when the MD doesn't make it known about a stat order. It's impossible to get them to behave and yes it's another responsibility for you too check.

We ALL have days when we are fed up with nursing and being everybody's scapegoat and punching bag.:hdvwl:

As a new nurse it can be over whelming......but it gets better!!!!:hug:

That is one of the downfalls to the CPOE we use too. You don't always know when a new order is put in and when it's a stat order it's good to know. We can't sit at the computer and refresh every minute to see if the doc put in an order and the docs can put in the orders from any PC at hospital or at home. We do chart checks with the CPOE although we don't have "charts" but it's not realistically to sit there and constantly refresh that on every patient. There should be something in place that if it is a STAT order that either the software notifies you or the doc notifies you they added one.

[metfan]

I really, really wish the doctors would just tells us they put a stat order in. It always seems to come down to communication. If they would take just a second to mention it, I would be greatful. I recently had a doctor right a stat order for a cardizem drip. He put it is the "pile" for the unit secretary. It easily could have been lost in the pile. Fortunately, I noticed it and hung the drip. I don't always see the doctors on the floor. They sometimes come and go so quickly. I am done venting now.

[thehipcrip]

There should be something in place that if it is a STAT order that either the software notifies you or the doc notifies you they added one.

The problem with software like this is that the geeks [and I use that term with the utmost respect ] who develop it have almost zero input from the actual end users, so they don't know about features like this that would make a world of difference when it come to patient care -- and enabling nurses to do their jobs more efficiently.

Have every nurse and doctor send this suggestion to the hospital's risk management folks and directly to the software manufacturer. In the age of Twitter, it should be no problem at all for the company that designed the software to build in a feature that automatically sends a text message to the nurse assigned to a patient for whom a STAT order has been submitted.

If enough of these suggestions [customer demands] are received, the feature will be included in the next software update and will soon replicate across products and become an industry standard.

[highlandlass1592, BSN, RN]

And is a perfect example of why we need more nurses in informatics & software development!

[Esme12, ASN, BSN, RN]

I don't understand. Why did she give a coumadin when a physician write an order for a vitamin K injection? Is it because doc told her that she is on coumadin?

The patient came is with stroke diagnosis the MD said, and I paraphrase, No ASA she's on coumadin give 5 mg stat. The nurse carried out the stat order and then discovered the INR was 5.5 (I believe). The nurse notified the MD about giving the Coumadin with the elevated INR and the Vitamin K order was received.

What I wonder is if this was an ED admit, why was the INR not addressed by the ED by at least mentioning it to the floor in report as a critical high(in most places) and why did the ED doc not tell the PCP/hospitalist and if the PCP/hospitalist knew the patient was on Coumadin why didn't they look at the lab values prior to writing any orders let alone stat ones......