Has this happened to you

brownbook · Nov 25, 2012

Yes the family can sue. I do not know enough about nursing legal issues. Do you have your own malpractice insurance?

Was an incident report made about the Lovenox? There had to have been many nurses involved in her care for that week who were also involved in her care.

Talk to your charge nurse, if she isn't much help go above her, up the chain of command, to find out what, if anything, you need to do.

Her language had nothing to do with this. Your patient could have been a native born English speaking trauma surgeon or gastroenterologists and they would not have known they were having a slow peritoneal bleed. The signs and symptoms are very subtle. No one could have noticed this until her H&H started dropping.

mappers · Nov 25, 2012

I'm a little confused. You bridge with Lovenox before the INR reaches goal. You stated "with the intent to bridge after an INR was reached". Is that a typo or do you not really understand how bridging with Lovenox works? Also an INR of 4 is way too high (not critical, but high). Most INR Goals are between 2 - 3 with about 2.5 being ideal. I would really question why a doctor would send a patient home with an INR of 4. How often were INRs being checked? How exactly were the orders written? If I had a patient with an INR over 2 and he/she was still on Lovenox, I'd question the MD.

Now as far as the bleed, if she wasn't complaining of pain and her H&H was OK, I'm not sure how you would have picked up on that.

brendacg · Nov 26, 2012

Thanks for your response. What I meant was that she was receiving lovenox and coumadin but the lovenox was supposed to be dc'd after the inr reaches 2-3 range. I guess the patient being non-english speaking was kind of irrelevant, but at the time made me feel like I wasn't giving the highest quality of care because of the language barrier. I applied for Liability Insurance today, just in case another incident like this happens again (which I am not exactly anticipating). There were at least 7 other nurses that week who cared for the patient, I'll be able to find out the next steps of what will happen tomorrow.

jadelpn, LPN, EMT-B · Nov 26, 2012

Usually, lovenox is a renew after 3 day drug. Depending on your facility policy. As well as coumadin is a daily order, dose depending on the INR, which is usually daily when you are just starting out. It is a policy issue, in my opinion. If you are not checking INR's when does one know when theraputic level is reached? Why is someone giving coumadin without a recent INR? Why are these drugs being renewed without the lab info? Even if it is every 3 days, the labs coordinate with the dosing,therefore, need to be done often. Coumadin also reaches its peak efficency in 48 hours--pharmacy needs to set policy to be followed. Don't ever give an anti coag unless you see the lab first. Was it a matter of people just giving the med without looking at the lab?

One of the first signs of a bleed is a drop in the H&H. So unless one has the information that something is changing in the H&H, there is visible bleeding, dark tarry stools, or signs of shock, then in fact you would have not a clue someone is bleeding. And a firm abdomen can mean anything--it is just a sign that unless it is coupled (or tripled) with something else, then hard to know.....

Doucument, document. Tell the MD if you feel a firm abdomen. Tell the MD that the INR was not done in a couple days, and the patient has xyz mg of coumadin and a lovenox bridge. An order that reads "lovenox until INR is between 2-3" has to have a check INR daily with it--even if it does not, to CYA, you could in fact ask for a daily INR order to accompany the lovenox bridge situation. There is a lot a JHACO information about anti coags and the monitoring of same. And finally, don't ever ever give a patient an anti-coag, just starting out with anti coag therapy--without a most recent INR--which ideally should be daily.

Been there,done that, ASN, RN · Nov 26, 2012

I have seen this scenario . If it was a gradual bleed, the CBC would not dip below normal until the cause was evident.

This is partly a pharmacy issue. It is also their responsibility to check the labs .. before the medication is dispensed. This is a pharmacy protocol your facility should have in place.

As far as nursing.. a retro-pertioneal bleed can have very subtle symptoms. Most likely numbness and tingling in the area and affected lower limb. Very difficult to assess if a language barrier is present.

My thoughts.. the pharmacy check was not in place.. you did what you could do. Do you have an interpreter available in your facility?

Ivanna_Nurse, BSN, RN · Nov 26, 2012

What is up with lovenox 50mg TWICE a day on a small statured patient?? Sounds like a full anticoagulation dose and 100kgs is not small statured. Ivanna

jadelpn, LPN, EMT-B · Nov 26, 2012

Lovenox is usually mg per kg, so a daily total of 100 mg would be for a 200 plus pound patient. So Ivanna is correct, that is a LOT of Lovenox.

brendacg · Nov 26, 2012

We do not have an interpreter at our facility, we never do... I had a meeting with the DON (along with another nurse and our unit manager) and this patient is in the ICU bleeding out. There were 6 nurses who gave the lovenox when they shouldn't have. Also, our nurse practitioner who wrote the orders for the Coumadin is also at fault. She wrote something like "Coumadin 10mg X 3 days" when the pt had an INR of over 3. The DON thinks that she will get the brunt of any disciplinary action, as well as the nurse who was taking the orders off and was aware of the INR from the labs. The DON seemed to believe that this would eventually be reported to the DPH and then the *#@& will really hit the fan... I'm not too sure how this will affect me (negatively, obviously), but at least this will make me a better nurse for the future and this is something I will never forget.

mappers · Nov 27, 2012

This is terrible. I hope the patient ends up OK. Sorry this happened to you and mostly to her.

Anna Flaxis, BSN, RN · Nov 27, 2012

It is the nurse's responsibility to know about the medications they are administering, and to check appropriate labs prior to administration. The NP might have written the orders, but the nurses who gave the Lovenox despite target INR having been reached are responsible for their own actions.

That is a hefty dose of Lovenox. Again, the nurse who administers the medication is responsible for knowing whether it is a safe dose. Every nurse who administered that dose without questioning the order is responsible for the outcome.

Also, keep in mind that Lovenox does not affect INR. The INR of 4 was caused by too much Coumadin.

The nurse who discharged the patient with an INR of 4 without notifying the prescriber is responsible for that. Even if the nurse did notify the provider who wrote the discharge order and that provider said to DC anyway, the nurse has a duty to advocate for the patient. The provider who wrote the order is not the final authority.

How could you have picked up on this? Well, you could have held the Lovenox and notified the prescriber when you saw that the target INR had been reached. You could have looked up the dose of Lovenox and noticed that this seemed like a high dose, and called the prescriber to clarify. If daily INRs weren't ordered, you could have asked the prescriber for an order for daily INRs. Whoever discharged the patient with an INR of 4 should have questioned the order to discharge. There is a lot that you and every other nurse in this scenario could have done differently.

Jenni811, RN · Nov 27, 2012

Hmmm...With medications @ our facility we have this new system that has been working really well. Mainly because we are all 100% computer charting. So we havea policy that medication orders can NOT be written as a nursing communication order (easily missed). What should have happened is the doctors, or pharmacist in charge of warfarin dosing should have discontinued the lovenox once the therapeutic INR was reached. I wouldn't blame it all on the nurses. But yes...unfortunate. What should have been questioned was not only the signs of a bleed, but also because she was being admitted for warfarin bridging. So it would be important to know her INR, and a nurse would have good reason questioning giving Lovenox to someone with an INR greater than 2 or 3.

We usually bridge with heparin, so its a little more controlled and shorter life but we do on occasion bridge with lovenox. Depends on how long, diagnosis, other diagnosis, the patient etc.