Errors--system problem or nursing problem?

nurseprnRN, BSN, RN · Feb 22, 2015

Your premise is that it has to be one OR the other? Not necessarily, in the case of most errors. It's often multifactorial, and I hate to say it because it will be distasteful to you, the nurse is the last defense against error or danger.

Your patient is scheduled for a thoracentesis. Pt is on Coumadin. Your assessment reveals mild SOB, but you know the thoracentesis and the Lasix you will give are intended to relieve it. Sats are fine on 2L NC, isn't in distress, but you will monitor closely. As you are reviewing meds and labs and notes, you see the specialist wants Coumadin held today, but the internal medicine team did not d/c it off the MAR. You also know the procedure team will want to know the INR before commencing. You see that Coumadin has been given every day, but no INR has been drawn for three days. You call the doc, confirm holding the med and request an INR be drawn. INR comes back 5.4, you report it along with your assessment of SOB and your concern that the procedure will be necessarily cancelled. Pt is stable thruout the day, and you come back on shift two days later and find out the patient went to ICU for respiratory distress. You know all of this might have been prevented with a daily INR and daily dosing of warfarin.
System problem or nursing error?

Perhaps a nursing error, because nobody noticed that his pleural effusion worsened while you were off two days? Nothing to do with anticoagulation unless he had an intrapleural bleed. Or perhaps his increasing respiratory distress was related to a worsening effusion because he wasn't tapped sooner, is that your premise?

If he needed a pleural tap that badly, they could have done it anyway with special attention to any bleeding at the site and extremely careful technique. Perhaps the ICU was the right place to do that. Nursing error for not catching it sooner and for not checking to see if daily INR is standard of care for anyone on long-term warfarin (it's not, but getting a baseline would have been prudent). Physician error for not checking too.

And "might have been prevented" isn't going to stand up in any court. When you left, he looked fine. Other standards of care for monitoring effusion and condition ought to have been in place, and probably were.

Pt is symptomatic with severe right-sided heart failure. Nitro-BID is on the MAR, prescribed BID, but the administration guidelines on the MAR state to provide a nitro-free period of 12 hours per day. You review the manufacturer's guidelines which state BID dosing should be six hours apart to allow for the 12-hour daily "vacation". Upon reviewing the MAR, you see the scheduling is 12 hours apart, and the patient has not received a nitro vacation in 96 hours. You call pharmacy to tell them of the problem and provide a suggested schedule that aligns with the manufacturer's recommendation.
System problem or nursing error?

Both. Nurses should know this about the drug they give. System should have a set of drugs for which "BID" means, for example, q12h, with breakfast and dinner, with breakfast and HS, 0800 and 1200, or whatever.

The idea that if there is any element of "system error" that absolves the nurse from responsibility is distasteful. I remember the famous case where somebody hung a wrong IV drip and killed a 16-yr-old in labor. There was much hue and cry about how she was working overtime (evil hospital, made her do it, if she's tired it's not their fault...SYSTEMS FAILURE!!) but the fact of the matter was, she violated the most basic rule of giving meds, which we all had beat into us from the first week of nursing school: the 5 (or six or seven, whatever it's up to now) rights-- RIGHT DRUG being first > NURSE FAILURE.

dudette10, MSN, RN · Feb 22, 2015

FWIW, systems error includes nursing, so I expect nursing to claim their part of it. What is distasteful to me is when systems error problems are remedied with a only a reprimand to the nurse. Did you not understand that about my comments in another thread?

Anyhow, I agree that both these problems were multi factorial.

Graduatenurse14 · Feb 23, 2015

What is distasteful to me is when systems error problems are remedied with a only a reprimand to the nurse.

This. It is far easier and way less expensive to go this route than really deal with the root cause(s).

Unfortunately it's not just in nursing, there are other professions where only one part is held responsible while there are many other factors in the breakdown that aren't addressed. I was a teacher before becoming a nurse and I've wondered how I've chosen the 2 professions that are the epitome of "high-responsibility but low-authority" and tend to get blamed the most when things go wrong. :banghead:

JustKeepSmiling, ADN, BSN, RN · Feb 23, 2015

Oh I have seen this types of situations all too often. IMHO... I am only one nurse with a 12 hour shift to fix/clarify/request orders. This issue is further complicated when the patient has 6 consulting physicians.

AJJKRN · Feb 23, 2015

I honestly feel like one of the biggest problems noted here is how we have to "police" everyone from other nurses (possibly with less experience or knowledge letting these systems errors fall through because the excuse of being too busy is just not excusable) or the doctors that order the meds/tests/etc, to the pharmacists and other professionals that don't communicate or catch these things before they're approved in the MAR or to become acknowledged orders. We absolutely are the Pt's last line of defense and we are juggling way too many hats, expectations, and different experience levels but...why are nurses generally the scape goats when we either can't keep up or don't have the experience with what is going on at the time to know better? I am accountable and proud to say that we have the knowledge, intuition, and multi-taking skills to do this but how many plates can one hold up when more and more plates are being stacked up and no ones taking any plates away? I'm pretty sure that my level of burnout and compassion fatigue (with only having not even four years experience) has to do with just wanting to be a good nurse, not a great nurse, just a good nurse, and being able to get my job done to my satisfaction without always (or damn often) having to back track and fix things that were put in motion, missed, or just plain overdue on top of a crazy night or even a regular night. It's wearing on ones soul. This topic does remind me though of how often a good physician has a great nurse (or nurses) behind them to make sure all their T's are crossed and all their I's are dotted. :unsure: :drowning:

AJJKRN · Feb 23, 2015

Whew...does anybody know how to use paragraphs when typing on your phone? Sorry Ladies and Gents!

calivianya, BSN, RN · Feb 23, 2015

I honestly feel like one of the biggest problems noted here is how we have to "police" everyone from other nurses (possibly with less experience or knowledge letting these systems errors fall through because the excuse of being too busy is just not excusable) or the doctors that order the meds/tests/etc, to the pharmacists and other professionals that don't communicate or catch these things before they're approved in the MAR or to become acknowledged orders.

You just hit the part of nursing that I hate the MOST on the head. I am so tired of policing other people. I just want to do MY job. I would be happier if I didn't have to do everyone else's, too.

I am tired of calling pharmacy to correct stuff like the nitro/Coumadin situations above. Yes, I know what those drugs are and how they should be monitored, but so does the PHARMACIST who should be aware of how those drugs work. If I'm not mistaken, the pharmacist went to school just to learn about drugs and such. Shouldn't he/she know how they work? I am tired of calling lab and asking for the THIRD TIME to have my labels printed out so I can draw my patient's labs (we have to use specific labels). I am tired of having to call a physician who ordered AC&HS fingersticks and q4h insulin to determine WHICH schedule they actually want us to follow. I am tired of getting an order for a PRN BP medication that doesn't have parameters in it and I have to call AGAIN once the order pops up in the system but has no parameters...

I really feel like a lot of these problems are ultimately IT errors. We use an entirely electronic system - how is it that providers/pharmacists/lab are allowed to enter things incorrectly or on a nonstandard schedule without having a warning pop up? If I am entering orders, and something is an allergy/contraindication/whatever, I get a warning box pop up. Why is there not a system in place that if you enter a medication and check q4h PRN, that some red flag pops up that you can't continue with the order until you put a PRN indication? Jeez Louise, we have an annoying pop up that comes up every single tab if I haven't added something stupid like a SKIN CARE PLAN if the patient had a low Braden score. Nevermind I am charting blood pressures in the 60s and trying to stabilize the patient... we have to have a plan of care for skin breakdown RIGHT NOW!!!

I feel like all the chart auditors in the world are breathing down our necks. Who is breathing down these other providers' necks? Besides nurses, of course. Someone else needs to be auditing this stuff, too.

calivianya, BSN, RN · Feb 23, 2015

And, specifically regarding the first scenario, I will say that one's not a systems problem - it's a physician problem. If the specialist wants to do a procedure, the internal medicine physician should be aware. If the internal medicine physician is aware, he should put an order in to hold the Coumadin. Or heck, let's talk personal responsibility for the provider performing the procedure - the specialist should put in an order to hold the Coumadin, and if the specialist is going to want to know an INR, he should order one. How hard exactly is it to think - oh, we're sticking a needle in a Coumadin patient tomorrow, maybe we should check an INR?

I resent the thought that this is a nursing error. Should nursing suggest to the physician very nicely that they screwed up and need to fix it by writing an order to hold the Coumadin and to check an INR? Sure, but it's not OUR error that an INR was not drawn. We don't write orders. Deciding that the patient needs an INR drawn, while obvious, is not in our scope of practice. I say the INR not getting ordered is the fault of the person whose ACTUAL scope of practice involves ordering labs. Just because I catch a physician's error and get it corrected doesn't mean the error is my error.

dudette10, MSN, RN · Feb 23, 2015

You just hit the part of nursing that I hate the MOST on the head. I am so tired of policing other people. I just want to do MY job. I would be happier if I didn't have to do everyone else's, too.
I am tired of calling pharmacy to correct stuff like the nitro/Coumadin situations above. Yes, I know what those drugs are and how they should be monitored, but so does the PHARMACIST who should be aware of how those drugs work. If I'm not mistaken, the pharmacist went to school just to learn about drugs and such. Shouldn't he/she know how they work? I am tired of calling lab and asking for the THIRD TIME to have my labels printed out so I can draw my patient's labs (we have to use specific labels). I am tired of having to call a physician who ordered AC&HS fingersticks and q4h insulin to determine WHICH schedule they actually want us to follow. I am tired of getting an order for a PRN BP medication that doesn't have parameters in it and I have to call AGAIN once the order pops up in the system but has no parameters...
I really feel like a lot of these problems are ultimately IT errors. We use an entirely electronic system - how is it that providers/pharmacists/lab are allowed to enter things incorrectly or on a nonstandard schedule without having a warning pop up? If I am entering orders, and something is an allergy/contraindication/whatever, I get a warning box pop up. Why is there not a system in place that if you enter a medication and check q4h PRN, that some red flag pops up that you can't continue with the order until you put a PRN indication? Jeez Louise, we have an annoying pop up that comes up every single tab if I haven't added something stupid like a SKIN CARE PLAN if the patient had a low Braden score. Nevermind I am charting blood pressures in the 60s and trying to stabilize the patient... we have to have a plan of care for skin breakdown RIGHT NOW!!!
I feel like all the chart auditors in the world are breathing down our necks. Who is breathing down these other providers' necks? Besides nurses, of course. Someone else needs to be auditing this stuff, too.

Thank you for this! I once started a thread about having to be the "mistake corrector" and "nag" for all the ancillary staff and docs, and someone came in saying so self-righteously, "Well, it's because we are the coordinators of care! If you don't like it, leave nursing!"

Really? Since when did coordinator of care mean I have to clean up other people's mistakes? Occasionally, ok, but every damn day MULTIPLE times? And they are just because people aren't paying any attention to what the hell they are doing! Am I the only one paying attention?! CNAs say, "I'm busy," and I'm forced to prioritize for them. Lab can't do a timed draw on time even when I call them three hours before, 1 hour before, and 1 hour after when I see that they've failed to draw. I saw RT tell one of my coworkers that he tried to draw and ABG twice, failed both times, threw her the ABG kit and told her to get someone else to do it! WHAT?! I couldn't pull something from the Pyxis one time, and I wasn't sure why...it was grayed out. I called the floor pharm who told me to call central pharm who told me to call the pharm tech who then told me to fix it myself. (I very sternly told her that I would NOT do her job, and it needed fixed NOW.)

I suggested to our QI CHF educator to seek out grants to improve readmission rates for the measured indicators. She didn't know what a grant was, and she told me, "Why don't you research grants and send me the links." I just looked at her and walked away. Honey, that's YOUR job; I'm a floor nurse.

jadelpn, LPN, EMT-B · Feb 24, 2015

In scenario #1, the patient needs should be looked at from day 1. This patient sounds chronically ill, with acute episodes that need to monitored.

The day of a procedure is NOT the time to draw an INR, and realize it is too high. Based on this, I would question if the patient was taking Coumadin correctly, or patient is not being monitored as closely as they should be. I would question non-compliance. I would also question why case management/health care team is not following this patient more closely.

With that being said, I would also question why this patient is not a candidate for an indwelling acities drain. Again, one's INR needs to be at a place of therapeutic levels, however, going forward this may be a thought. And for Home Health to monitor this patient more closely, daily INR's, (long term Coumadin?) and daily Lasix compliance. (there are more people than one can shake a stick at who just don't want to pee all day--)

That a nurse such as yourself would advocate for increased services going forward could only be a good thing. This patient apparently had no long term monitoring. Because you are the messenger of this discovery doesn't make you an unsafe nurse. The process for this patient needs to change. If you are in a place where you can say "hey, this is a patient that needs monitoring and extended services" (as for most acities is not a one time gig) follow through with the MD, social services, case management, DOCUMENT that these referrals were put into play, this is the only thing I can see that is within your control.

Scenario #2

The MD needs to be more specific in clarifying this order. And when reviewing medications for one's patients, I would question this. Does the MD want a nitro vacation? Can you pass your suggestions of times to the MD? By discussing this with pharmacy, you are teetering on the edge of prescribing. This is a good learning moment, however, that a specific policy needs to be put into place for long term nitro use. Then everyone is on the same page. There are MD's who don't "believe" in nitro vacations, regardless of the manufacturer's recommendations. (It is akin to Vanco peaks and troughs) A policy that is backed by evidence based practice could be in order.

Each patient is unique, under a unique set of circumstances. If you are finding that a ball is being dropped into your lap, you can only advocate for a change, ask for clarification, make sure that you are taking your assessment findings and doing something with them.

icuRNmaggie, BSN, RN · Feb 24, 2015

For our discussion...
Your patient is scheduled for a thoracentesis. Pt is on Coumadin. Your assessment reveals mild SOB, but you know the thoracentesis and the Lasix you will give are intended to relieve it. Sats are fine on 2L NC, isn't in distress, but you will monitor closely. As you are reviewing meds and labs and notes, you see the specialist wants Coumadin held today, but the internal medicine team did not d/c it off the MAR. You also know the procedure team will want to know the INR before commencing. You see that Coumadin has been given every day, but no INR has been drawn for three days. You call the doc, confirm holding the med and request an INR be drawn. INR comes back 5.4, you report it along with your assessment of SOB and your concern that the procedure will be necessarily cancelled. Pt is stable thruout the day, and you come back on shift two days later and find out the patient went to ICU for respiratory distress. You know all of this might have been prevented with a daily INR and daily dosing of warfarin.
System problem or nursing error?
Pt is symptomatic with severe right-sided heart failure. Nitro-BID is on the MAR, prescribed BID, but the administration guidelines on the MAR state to provide a nitro-free period of 12 hours per day. You review the manufacturer's guidelines which state BID dosing should be six hours apart to allow for the 12-hour daily "vacation". Upon reviewing the MAR, you see the scheduling is 12 hours apart, and the patient has not received a nitro vacation in 96 hours. You call pharmacy to tell them of the problem and provide a suggested schedule that aligns with the manufacturer's recommendation.
System problem or nursing error?

Neither. These are medical mismanagement /management issues.

The right sided heart failure patient may need 24hr vasodilators due to pulmonary hypertension. That order needs to be clarified.