Jump to content

Heparin dttp error- Ready to just out of my skin.

Med-Surg   (370 Views 3 Comments)

TtheIndecisiveRN is a BSN and specializes in M/S.

176 Profile Views; 8 Posts

Hey everyone. I just finished a shift and needed to vent! Firstly, I finished my shift and i was feeling POWEFUL! As a novice nurse, finishing your assignment with tons of¬†time to spare, comfortable, satisfied patients¬†and charting absolutely complete felt so good. Until I gave report ūüė≠. During report The oncoming nurse & her orientee¬†brought to my attention that I made an error.

My patient was receiving heparin dttp and has been therapeutic for days. I had her the day before and I did not have to play with the heparin at all so the new dosing was honestly unexpected for me. Anyways, I changed the dose after¬†receiving the new PTT. it was¬†appropriately verified by another RN. BUT I DID NOT ORDER A NEW PTT after 6hrs. (Dammit.) by report it had already been 8 hours (6:40am instead of 4-4:30am).¬†¬†I misordered a lab time for the therapeutic draw (24hr of the initial draw) vs the q6 draw when nontherapeutic . So my patient received a possibly wrong dose for two extra hours. ¬†ūüė≠ the patient was fine no changes to tele, chem 7 or assessment.¬†¬†The patient¬†did develop a jerk like involuntary moment (almost like when you dry heave) through the night but I was assured that was unrelated ¬†

I reported the error to the MD, my charge nurse, manager and created a incident report just for formality. But unfortunately the nurse I gave report to was really condescending & immediately sought to report me and now I’m in bed feeling defeated. 

I definitely learned my lesson and will maintain the habit of reviewing the protocol with another set of eyes so I don’t make this error again but jeez I feel like crap. 

What do you do after a med error? Have you ever felt so bad and how do you feel better? 


Thanks for reading. 

Share this post

Link to post
Share on other sites

caffeinatednurse has 3 years experience as a BSN, RN and specializes in Med-surg, telemetry, oncology, rehab, LTC, ALF.

266 Posts; 3,824 Profile Views

Given that you are humble enough to recognize your error (you'd be surprised just how many nurses *refuse* to see their error) and that you reported it to all appropriate parties, I really think that you should cut yourself a break.

Is it a med error? Yes, of course it is. You inadvertently gave the patient too much heparin. You will always remember this med error, unfortunately. And it is because you will always remember this that you will likely never make this med error ever again. You will always double check the heparin protocol, from here on out. And one day you'll be able to guide a new grad through the protocol with just a touch more wisdom than someone who has never made that error. It's unfortunate, but what's important is that you learn from it. 

Also, the nurse who co-signed your heparin gtt should have also verified when the next PTT draw would be. I usually stand there with the nurse I'm co-signing for and make sure they put the lab order in before I walk away. Just something to think about. We all get busy, but you can never be too careful when it comes to anti-coagulants. 

Share this post

Link to post
Share on other sites

romantic has 9 years experience and specializes in Med-surgical; telemetry; STROKE.

182 Posts; 6,163 Profile Views

Hi TheindecisiveRN.

First of all, change your name (TheindecisiveRN) to something funny, or strong, or beautiful, or cool... You don't want to be weak and hesitant nurse... 

About your medical error.

As a new nurse you will have your number of mistakes. We all had that period of learning curve when we made mistakes. Just prey that your mistakes will not kill your patient; be super vigilant, question any medication to be given by you, find your favorite person you can ask about the medication you don't recognize; do not rush yourself-- it is better to be late than to make a mistake.

It is very good that you wrote yourself up after making mistake. It is better to reveal your mistake than let someone else do it for you. 

The mistake you made is not that terrible. I noticed a few times that nurses for some reasons were late with Anti Xa: or the patient is a very difficult stick, or something else happened. A few hours of delay will not kill your patient. It is very good that you called and notified the doctor. They need to know why the result is this instead of that. 

Tell yourself:  "I can do it! I'll be the best nurse on my unit!" Do not let this incident put you down. 

study. study. study.




Share this post

Link to post
Share on other sites