Oh man did I miss an order

Nurses General Nursing

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ok I had the same pt for 3 nights in a row. She had issues w/ blood loss, on day 2 received 2 units prbc. Crit went from 20 to 23. Afternoon crit on day 3 was 26. I call the resident. He said "Ok, thanks" and that was it. So I do my work for the shift. We were all working over-ratio d/t high census.

That specific patient was feeling great. Her color was good, her vs were stable, everything was good, she was up and walking. I took off her order for d/c in the morning and all was good.

So fastforward to today. I have the day off. I just get a call from one of the nurse supes. Apparently a doctor came over and wrote an order FOR A BLOOD TRANSFUSION at 1800 AND DID NOT TELL ANYONE. I am nuts about checking my charts and I don't know how I missed it. Said dr. apparently said that he couldn't find a nurse so didn't tell anyone about it. Ok right sure. That MIGHT be true since we all were over ratio and running around like lunatics. But I saw no red flag, no stat anything to indicate something had to be done. i DO check my charts at least once a shift and more as needed.

The patient, when informed around midnight or so by the next shift that she needed a transfusion, said that she had not seen nor spoken to a doctor at all in the evening. No one had told her about it, and she ultimately refused the transfusion.

She was fine, left in the am as planned, no harm done. That was the bottom line.

I was told "don't beat yourself up, don't lose sleep over it." Ok sure right. I told my supe that I of course accept responsibility for my part in this, and I will do whatever they need me to do, but at the same time, a blood transfusion order is a lot different than an order for tylenol or something, and the resident really should have said something to ANYONE and she totally agreed and said communication really takes two people.

Here I had this woman three nights in a row, spent lots of time with her, worried about her on my off time, trying to figure out why her crit had dropped and celebrated with her when it started going up. I thought I did really good last night with five couplets and one being a fresh-postop.

I feel terrible...

...just now supe called me back and said its the resident's fault. Reason being, I checked my charts all at the beginning of my shift and hers had the discharge order. Supe said that since I planned to d/c her, and that the resident's response to the crit was "ok thanks" AND that a crit of 26 is not so bad and we normally don't transfuse for 26, that she is bringing it up to the director as the resident's lack of communication to the nurses. She said she also called me back to tell me I am an excellent nurse and that she knew I'd be beating myself up about it and I should stop.

Ok so how do I stop? I missed something. I asked her if I was in some kind of trouble and she said no. I told her I'd do whatever I have to. But I am bothered by the fact that I let my patient down, even tho the patient doesn't know. That is what bothers me.

I feel awful.

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You didn't let the patient down, she could have had the blood at midnight, she refused it. Wasn't the doctor notified of the refusal? She might have refused it on your shift as well.

I wouldn't worry about it.

What the sup said is correct.

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I don't think there is anything anyone is going to say to you that will make you feel less responsible. It seems to me that you are a very conscientious and diligent nurse. I don't see anyway that you could have done anything to prevent this, unless you start checking charts every 15 minutes and stalking to doctors. Be comforted in the fact that the patient is ok and that the supervisor is on your side. Hang in there!!! :icon_hug:

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Specializes in LDRP.

Do you not have a secretary who enters orders? Wouldn't she have seen it and alerted you? Or did he write an order and then stick the chart back on the shelf and leave it there?

When do you check your charts? Checking them right before giving report, or right after report, right before leaving could prevent this in the future.

No harm done, though, don't beat yourself up :) Hve you spoke to this resident since?

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Specializes in FNP, Peds, Epilepsy, Mgt., Occ. Ed.

You checked the chart and had discharge orders. It's not common to get other orders once those have been done. Then the resident didn't find you nor anyone else, didn't flag the chart, and had already told you "Oh, OK" when you called on the blood work.

Apparently your crystal ball wasn't working that night.

I don't remember ever making a habit of always checking every single chart, after the initial check, just in case someone had written something while my back was turned. If I saw someone with the chart, yes, but not every unflagged chart.

You do have to take a look at your patients every now and again, you can't babysit your charts the entire shift.

Give yourself a break and yes, be thankful you've got such a great supervisor! It takes backbone to stand up for her nurses.

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Specializes in telemetry, cardiac intermediate care,.

it's not your fault. i have found some charts racked with orders on them after i have check them too.

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Specializes in ED, ICU, Heme/Onc.

The order was written at 1800 and no one told you that it was there, and the chart wasn't flagged. Sure, in a perfect world you would have read the resident's mind that "OK, thanks" means "give a unit of PRBCs".

Some hospitals have a direct order entry system where the docs enter their own orders. ie - a doc puts in an order for PRBCs directly into the system and the blood back receives it and calls the unit when the blood is ready. Sure, its nice when the nurse gets a heads up, but the order gets through. This system eliminates situations such as this one. And the nurse's order screen has everything ordered since the date of admission all there in a nice, tidy list.

I'm starting a new job where they use the paper chart/nurse enters all orders from a direct order entry computer system. Thanks for the heads up on that and I still think its mostly (like 99%) the resident's fault.

You seem like a dedicated professional. You knew that you normally don't transfuse with a crit of 26, so why would you seek out a transfusion order w/out warning? As for how you can let this go... how about writing a letter to whomever you feel you've wronged, then destroy it. You'll get it all out, and then you can get rid of it. Hey, it just might work.

Blee

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Specializes in Day Surgery/Infusion/ED.

Stop it. Stop it now.

It's the doc who should be tormenting herself. She dropped the ball because she couldn't be bothered to look for a staff person when she added the order. Plus she didn't even bother to flag the chart.

You did absolutely nothing wrong. Hold your head up and accept the feedback from others that you're a great nurse.

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as far as i'm concerned the resident dropped the ball twice. first, he could have discussed with the patient about the need to transfuse blood. second, he did not "flag" the chart nor notify staff. "i couldn't find a nurse," gee, i'd like to see a nurse be able to use "i couldn't get in touch with the doctor," as an excuse.

it was the resident's responsibility to flag the chart and/or notify the nurse taking care of the patient.

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i feel that this highlights a major problem of nurse/doctor communication; or lack there of. we truly need to sit down and come up with better communication systems. i see this as a system error more than as a human error. pointing fingers will not help the patient's hg/hct. coming up with a solution however will help.

any new order entered prints to our printer and the unit secretary puts it in our box; decent but not perfect. if i'm busy, it might sit for a few hours.

i feel like medical and nursing schools should be intertwined, classes should be together (when possible); hospital orientation should be together (when possible) and open communication should be nurtured (always). there is still the invisible wall between us. it need to be ripped down. we should speak openly with docs and them with us.

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Specializes in cardiac med-surg.

do md's learn in med school how to flag orders????

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Specializes in ICUs, Tele, etc..

A solution for missed orders that is used by a lot of nurses so that they can cover themselves is the end of shift chart audit with the oncoming nurse. Therefore a nurse can go home knowing that when she checked off with the oncoming nurse, all the orders throughout the shift was taken care off. It takes only a minute.

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