I am new to cardiac unit and orienting. Had a patient scheduled for CABG the next morning at 0830. Stents were placed a few days earlier and Plavix was ordered by MD. Plavix was a new med for this patient. A dose was given 48 hours prior to CABG by one nurse and I gave a dose at 1000 am the morning BEFORE (the day before) his surgery. The preop order was not checked off to stop Plavix. Today, I was called into my managers office asking me about giving the Plavix because the patient had to be taken back to be reopened due to postoperative bleeding and oozing. He also had other arteries that were blocked which required additional surgery.
I've done research online and read differing opinions about giving Plavix before surgery. Some say to stop this med 5 days preop, some say 48 hours preop, due to risk of hemorrhage. Other studies conclude Plavix is not a serious reason for postoperative bleeding as there are multiple reasons a patient could bleed out.
I was interviewed by my manager today and am told she is considering firing me because I gave the Plavix and should have known better considering I am a seasoned nurse. To a point I agree with her, but in other ways I do not because its been a few years since Ive worked in a hospital setting and she knew that before hiring me and also because I think its harsh to fire me by pinpointing the reason the patient had postoperative bleeding is because I gave Plavix that should have been held. To say I am completely the reason enough to warrant termination makes me feel like walking on pins and needles with absolutely no wiggle room taking the full brunt of this patients postoperative complication. I am not a heart nurse, though I have floated many times to the cardiac floors and was being oriented. Believe it or not I am a very good nurse and have 12 years Med Surg under my belt, precepted student nurses, trained new employees, etc. I feel like their fall guy to make the patients family happy by telling them they fired me as to put the spotlight on me for this patients complication. If its my fault then I will take responsibility for it. So please - anyone out there experienced in Cardiac Nursing, I would seriously appreciate your honest opinion and input. Do you think this warrants being terminated or is Administration CYA's?
I love nursing, but honestly, I am really depressed right now. I have been thinking of leaving this profession because of the demands of nurse/patient ratios, poor organization on floors, yet requiring nurses to be nearly infallible. Im just really discouraged right now.
I just wanted to say that I think you're making a smart decision by leaving. Your manager sounds horrible. You might consider turning in your letter of resignation before she has the chance to fire you.
I did hand the manager my letter of resignation. She said she would put it my file but that their decision was to "let me go" with a no rehire status. The first time we discussed this (before they decided) her demeanor was not as harsh informing me that if they did decide to terminate me it wouldn't affect my job reference. But when I went in to meet with her and another ICU Nurse Director, I think it was more of a power trip they were on. I told them both it was punitive and harsh to fire me for something like this. Usually an incident report is filed and likely some disciplinary action; but not getting fired over ONE isolated med error! I have never been fired in my life over 12 years in my nursing career so sitting there in that office resisting shame and intimidation was very difficult. I listened carefully to their rationale and finally spoke up telling her "I am good nurse. Just because I made a mistake doesn't make me a bad nurse. The PCM angrily replied, "Well WE think you are!" To that I looked her straight in the eye and calmly answered, "That's your opinion... but it's not mine, all the patients I've cared for over 12 years, or all the previous managers I worked with." I think me standing up for myself made her even more angry because that's when she said, "Well, it doesn't matter because you will never work for this facility or any affiliated facility in this area again because we are not recommending you for rehire!"
I just let it go and told her that there are many other nurses working there that should be sitting in this chair than me, namely one who was verbally and physically abusing an Alzheimer's patient by screaming at him and manhandling him because he didn't understand what was going on and had soiled the bed and was being noncompliant. And I asked her what is she going to do about the Pharmacist who made the mistake of putting the Plavix on the Mar, or the nurses who preopp'd this patient before surgery, or the nurse that gave him a dose the day before me? She said that was none of my business.
The point to me is I gave them my letter of resignation and had it ready to give to them before this meeting. Even if they would have decided not to terminate me, I would have resigned. After a week of orienting there, I got bad vibes that one wrong move and I will be out of there. I have never felt this way about a place.
When I left, I went straight to the hospital I use to work and ran into an old nurse friend who had no idea I had just went through this being told I wasn't a good nurse. She asked how I was and where I was working but I didn't tell her what had just happened 30 minutes ago. She said I should come back to work there, because I was such a good nurse and was good at what I did. I am back working where I belong with nurses and people in charge who treat people the way they want to be treated.
BTW: Plavix acts in that it inhibits platelets causing them not to work like they are supposed to. It doesn't decrease the number, it only makes them act stupid over the life of the platelet which is approximately 7-10 days. This is why we should stop Plavix 5-7 days before a scheduled surgical procedure. According to the nurse manager, they claimed I was the only one who gave Plavix 75 mg the day before surgery because the pharmacist made the mistake. I clearly saw it given on the MAR the day before and the computerized med cart! They are lying.
Thanks everyone for your help. Its wonderful knowing we can come here and get the help and knowledge of our peers when we need it.
You were definitely their scapegoat. A single error like that is not adequate reason to crucify you as they did. Zookeeper3 was right in that MI patients will get Plavix within hours before emergent open hearts and have no complications, beyond what can arise from being "emergent" instead of "elective". In fact, it is standard at my facility for an MI patient to receive either 300 mg or 600 mg of Plavix before going to heart cath (depending upon the platelet count and other factors). A 75 mg dose wasn't desired, but it doesn't make you a "bad nurse" in that you gave it without a doctor's order to hold it.
If you had stayed in the setting, it would have just been a lesson chalked up to experience. Your work record from that point on would have shown that it was a fluke due to your lack of experience in the setting. Those of us who have worked in the area for a while just call the surgeon and clarify whether the med needs to given or held prior to surgery.
I forgot who else posted it, but they were correct. The heart surgeon is never wrong. We're currently being watched like hawks because of the high infection rates of 1 surgeon. (There are 7 or 8 heart surgeons working at my facility, with only the 1 having problems.)
Specializes in CCRN-CMC-CSC: CTICU, MICU, SICU, TRAUMA.
I'd like to know if the MD that didn't stop the Plavix is being called to the mat the same as you are...There is a rationale here for continuing the Plavix since the pt. was newly stented and the physician didn't check the box... I'm so sick and tired of this type of stuff with physicians... Why isn't the surgeon accountable for doing the surgery without being familiar with the MAR and knowing the pt. had the Plavix (presumably prescribed by the interventional cardiologist?)...Why is nursing always the fall guy as you say? On the other hand, I've been screamed at for paging a surgeon after a carotid endarterectomy and asking if he really wanted the ASA given... at which point he asked me "Do you want the pt. to stroke?"... at which point I said... "No, most certainly not, but I didn't want the physician to stroke either, so I'm asking..." It's precisely this culture perpetuated by these types of situations and physicians not being more careful in their orders and documentation that accounts for clinicians seeking more professional work environments resulting in short staffing and costing hospitals, on average, the nurse's salary in expense to restaff each position vacated (as evidenced by JCAHOs White Paper report)... Nursing loses either way... if you call and question and if you don't. I don't prescribe, as another nurse posted in response to your thread...when I do I want a bigger salary... I don't feel you are accountable here unless the rest of the team faces the same reprimand...
We have been forced to be so meticulous on following up every order and I catch stuff like this all the time and have it redone... instead of being at the bedside where I should be...What more can we do other than write all the pre-op and intra-op and post-op orders ourselves and then put it on a clipboard and move it under the physician's hand in the fashion of their signature?!!!!!!!!!!!!!!!
I am so sorry you have to go through this... I'm sorry for all of us...I didn't sleep at all least night over the issue I recently posted... I would have been on the MICU for overtime today (not my home unit) to provide relief... but was too tired from being sick to my stomach last night tossing and turning over the surgeon that lied... so I lose $500 in OT and they are short staffed because of this type of nonsense because I wouldn't come in to bail them out...
The ramifications of these behaviors and slams to nursing are huge... it affects everything... including the bottom line for the hospital...
When you do catch a mistake do you get a reward? Absolutely not... then you are just doing your job... does the physician thank you? Absolutely not...
I had another incident where the invasive cardiologist ordered a pressor to titrate according to my IABP Aug pressure... except it wasn't helping because he wrote a Levophed dose on a Neo prescription... Just my luck that he was mid-case in the cath lab and I had to point it out overhead with the Cath team listening in... "the nurse thinks you either wrote the wrong dose on the right medication or the right dose for the wrong medication"... The physician would not admit to it and I'm sitting there titrating Neo at 12 mcg (our standard protocol is start at 100 mcg then titrate to effect)... I would probably get just as much pressure support by putting the drug insert at the head of the bed... to save face he pretended it was his clear intention and left the patient dropping his pressure instead of saying "Thanks for covering my ass nurse... good call... let's change that to this..." So the nurse gets made a fool of and the patient suffers...
I used to protect them in my charting as well... I would leave out that phone call in my nurse's note... now I objectively include it... "Dr. Soandso paged, siutation, background, assessment, recommendation of such and such provided, current pressure xyz, order questioned, physician verbalized understanding of such and such a dose written on such and such a medication. Order confirmed. No change ordered." That way when I'm called to the mat I can say to my supervisor... "Are you familiar enough with this case to question the situation?... Have you read my note yet?... I'd prefer you read the notes before this conversation..." Maybe that's why I'm not called in much.
You are certainly not alone in these experiences... it is heinous... and I don't blame you for wanting to get out... but give another unit a try... or another hospital before throwing in the nursing towel... seriously...Seek out a more professional environment...You may very well find one...
I know it's easier said than done... I'm facing the same decisions myself...
I know you (the OP) have already worked hard to put this behind you, but something has piqued my curiosity - since I've now precepted 3 consecutive new hires without a break between. Where was your preceptor in these discussions with your manager, since it seems you were still in orientation? I've learned in the past to always review what meds are due before allowing my orientees to actually follow through and give them. (Patient with an EF of
Was your preceptor "disciplined" too? Ultimate responsibility for medications always lies with the MD. Next would have been your preceptor, and then you - at least to my way of thinking.
Okay, IMHO your old manager was a WITCH. Just had to get that off my chest.
I went to a meeting this past Feb at a Pri-Med convention in Florida and there was a two hour long lunch meeting related to this very issue. The issue was mainly patients coming into the ER and rec'ing Plavix before cath, bleeding associated with the cath and then having to make the decision to take them to CABG with their coags high. (i have the report it you'd like it I can try to send it to you electronically) BASICALLY, what they found was that if you give them plavix within 5 to 7 days of OR they tend to have worse outcomes. Interestingly, the room was loaded with cardiologists and Thoracic surgeons and very few of them used that as a treatment standard.
As I see it. There IS a problem giving patient's Plavix close to CABG, BUT FIRING someone is not the answer. It's an opportunity to look at the hospital's policy to determine a way to keep it from happening again. The Cardiologist and the Thoracic surgeon and the Pharmacy need to be on the same page. Set up a Pre-op CABG protocol and have EVERYONE follow the same protocol. If there is a deviation, DOCUMENT IT IN THE PROGRESS NOTES for Christs sakes (Pt will remain on plavix unitl 24 hours before surgery 7/21/08, related to new stents and risk of stend failure due to clots). I have to remind doc's all the time to DOCUMENT what's going on so I don't have to read their minds.
As I see it. Your manager miss a chance to make a HUGE improvment in the Telemetry AND the ICU of your facility. She SHOULD have asked to to head up a work group to see what the best practice was across the area and to write a proposal to submit to the Medical Excutive committe to see if you could get a meeting with them to discuss the new protocol that you and she could have authored. What a way to get recognized for not only saving lives, but for being a great manager. Obviously, she missed the boat.
I think you did a smart thing by leaving the facility, wanna come work with me in Atlanta, we have a new job opening in our department as of yesterday, LOL
There IS a problem giving patient's Plavix close to CABG...
The patient only had a supposedly dose of 75 mg of which the manager claims the doctor never ordered. Would a single, random dose, harm this patient in terms of postop complications - or even death a week later? The recent news is the patient died several days postop. Of course they never told me this when I was terminated. They said he was doing fine, out of the unit and back on the floor about to be discharged. What a bunch of liars.
What a night mare this so-called nurse manager is. Really a paid coward willing to stab people in the back to protect her job and these higher ups in my straight forward opinion.
).... wanna come work with me in Atlanta, we have a new job opening in our department as of yesterday, LOL
Ironically, I don't live far from Atlanta... just a hop and a skip really. However....this latest event has really done me in with nursing in a hospital setting. Im burned out after 12 years and have sworn never to work for a hospital again...though I AM a very good nurse. You work your butt off for what? For all the political crap like this? Hospital Nurses work harder than most people realize. I've had enough. There are not enough rewards to keep me in this setting. Its time for me to move on.
BTW....thanks and to everyone who have posted. I really value your thoughts on this. Somehow, it gives me comfort reading all the opinions and knowledge about this sad situation. Never in all my years of nursing have I ever been so badly treated, nor ever conceived someone in administration would stoop so low as this. Better said, never thought it would happen to me. It can happen to anyone.
PLEASE SEND A DETAILED ACCOUNT OF THIS TO YOUR HR, NURSING ADMINISTRATION AND THE PRESIDENT/DIRECTOR OF YOUR HOSPITAL.
SO WRONG, IN SO MANY WAYS! I am so sorry that happened to you. Maybe it was a blessing in disguise. Anyway, those Nurse Managers need to be called out! No one should be covering, and no one person should be a scapegoat. Where was your preceptor, if you were still on orientation? Too many unanswered questions....don't forget to send this to risk managment too!
Wow, you totally got dealt a bad hand. I just skimmed most of the responses, so sorry if this has been adressed, but isn't their some sort of communication from the floor to the pre-op? (Not saying you are at fault, just pointing out that there's a flaw in the system if there isn't..) Where I work we have a surgical pre-op checklist and a cath lab check list, both of which list meds that could affect pt's ability to clot (heparin, coumadin, plavix, aspirin). The sheet has you mark down whether the patient is on a med, and if so the last time they received it. I'd say that it's to avoid exactly the situation you described. You should NOT have been treated that way; sounds to me like their system is BROKE!!
I am new to cardiac unit and orienting. Had a patient scheduled for CABG the next morning at 0830. Stents were placed a few days earlier and Plavix was ordered by MD. Plavix was a new med for this patient. A dose was given 48 hours prior to CABG by one nurse and I gave a dose at 1000 am the morning BEFORE (the day before) his surgery. The preop order was not checked off to stop Plavix. Today, I was called into my managers office asking me about giving the Plavix because the patient had to be taken back to be reopened due to postoperative bleeding and oozing. He also had other arteries that were blocked which required additional surgery.
I've done research online and read differing opinions about giving Plavix before surgery. Some say to stop this med 5 days preop, some say 48 hours preop, due to risk of hemorrhage. Other studies conclude Plavix is not a serious reason for postoperative bleeding as there are multiple reasons a patient could bleed out.
I was interviewed by my manager today and am told she is considering firing me because I gave the Plavix and should have known better considering I am a seasoned nurse. To a point I agree with her, but in other ways I do not because its been a few years since Ive worked in a hospital setting and she knew that before hiring me and also because I think its harsh to fire me by pinpointing the reason the patient had postoperative bleeding is because I gave Plavix that should have been held. To say I am completely the reason enough to warrant termination makes me feel like walking on pins and needles with absolutely no wiggle room taking the full brunt of this patients postoperative complication. I am not a heart nurse, though I have floated many times to the cardiac floors and was being oriented. Believe it or not I am a very good nurse and have 12 years Med Surg under my belt, precepted student nurses, trained new employees, etc. I feel like their fall guy to make the patients family happy by telling them they fired me as to put the spotlight on me for this patients complication. If its my fault then I will take responsibility for it. So please - anyone out there experienced in Cardiac Nursing, I would seriously appreciate your honest opinion and input. Do you think this warrants being terminated or is Administration CYA's?
I love nursing, but honestly, I am really depressed right now. I have been thinking of leaving this profession because of the demands of nurse/patient ratios, poor organization on floors, yet requiring nurses to be nearly infallible. Im just really discouraged right now.
I work in a Doctor's office, before any surgery Pre-op Procedures are done, Ekg's blood work, and always directions on Coumadin, asa, Plavix, any of these meds are always considered before surgery, Most of the time it will be the PCP or in this case the hospitalist who determines when to stop. Some will be the Cardiologist that make this decision. If the patient was due for a CABG, Lovenox would be the drug of choice, last only 12 hrs, this keeps patient therapeutic while waiting for surgery. It should have been questioned.
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RN75
15 Posts
I did hand the manager my letter of resignation. She said she would put it my file but that their decision was to "let me go" with a no rehire status. The first time we discussed this (before they decided) her demeanor was not as harsh informing me that if they did decide to terminate me it wouldn't affect my job reference. But when I went in to meet with her and another ICU Nurse Director, I think it was more of a power trip they were on. I told them both it was punitive and harsh to fire me for something like this. Usually an incident report is filed and likely some disciplinary action; but not getting fired over ONE isolated med error! I have never been fired in my life over 12 years in my nursing career so sitting there in that office resisting shame and intimidation was very difficult. I listened carefully to their rationale and finally spoke up telling her "I am good nurse. Just because I made a mistake doesn't make me a bad nurse. The PCM angrily replied, "Well WE think you are!" To that I looked her straight in the eye and calmly answered, "That's your opinion... but it's not mine, all the patients I've cared for over 12 years, or all the previous managers I worked with." I think me standing up for myself made her even more angry because that's when she said, "Well, it doesn't matter because you will never work for this facility or any affiliated facility in this area again because we are not recommending you for rehire!"
I just let it go and told her that there are many other nurses working there that should be sitting in this chair than me, namely one who was verbally and physically abusing an Alzheimer's patient by screaming at him and manhandling him because he didn't understand what was going on and had soiled the bed and was being noncompliant. And I asked her what is she going to do about the Pharmacist who made the mistake of putting the Plavix on the Mar, or the nurses who preopp'd this patient before surgery, or the nurse that gave him a dose the day before me? She said that was none of my business.
The point to me is I gave them my letter of resignation and had it ready to give to them before this meeting. Even if they would have decided not to terminate me, I would have resigned. After a week of orienting there, I got bad vibes that one wrong move and I will be out of there. I have never felt this way about a place.
When I left, I went straight to the hospital I use to work and ran into an old nurse friend who had no idea I had just went through this being told I wasn't a good nurse. She asked how I was and where I was working but I didn't tell her what had just happened 30 minutes ago. She said I should come back to work there, because I was such a good nurse and was good at what I did. I am back working where I belong with nurses and people in charge who treat people the way they want to be treated.
BTW: Plavix acts in that it inhibits platelets causing them not to work like they are supposed to. It doesn't decrease the number, it only makes them act stupid over the life of the platelet which is approximately 7-10 days. This is why we should stop Plavix 5-7 days before a scheduled surgical procedure. According to the nurse manager, they claimed I was the only one who gave Plavix 75 mg the day before surgery because the pharmacist made the mistake. I clearly saw it given on the MAR the day before and the computerized med cart! They are lying.
Thanks everyone for your help. Its wonderful knowing we can come here and get the help and knowledge of our peers when we need it.