Heparin Error - Distraught

I'm sorry this happened to you! Could you give some more details of how it happened? What kind of miscommunication happened?

Hi

I'm sorry this happened to you and to your patient. This was potentially a very serious mistake & I'm sure you will learn from it. It is very important that we learn from these mistakes.

You need to give us just a bit more information as others have said.

Number one, we don't have any IV's off a pump much less a medicated drip.

For heparin & other dangerous meds, we have more then one person for checks.

Our pharmacy also plays a big role in our heparin protocal. It is mainly the pharmacist who will tell us when & how much to adjust our drips. However, we are expected to check each other. In other words, don't just take his word for it, actually do the calculations yourself & make sure it is correct.

If there is a discrepency, discuss it, don't just assume he might be correct. Everyone can make mistakes & that is why we need to check ourselves.

I work Oncology & we check every single calculation for dosages & it is checked by 2 ONC RN's plus the pharmaccy.

We check PTT's q 6 hrs. at first until it becomes therapeutic & then we change to daily. It takes some folks quite a while to become stabalized.

Anyway, Good Luck; Please realize we all make mistakes & what is most important is that we learn from them.

Mary Ann

You are not a bad nurse. You are a human being who made a mistake. Own the mistake, don't deny it. Learn what you need to learn from this, learn how to not do it again, then dust yourself off and keep on moving on.

Med errors are devasting, I know. Good luck to you.

So sorry for your error.Don't beat yourself up. I have to ask, because I have noticed a tendency to take things at face value lately, was the mis-communication information out of the ordinary? I have noticed lately that some nurses are not questioning factors about their patients the seem unusual, when doing so can prevent an error. For instance, the other day a nurse reported to me that a patient had ac/hs blood sugars, and had had two sugars greater than 250, but had no insulin coverage ordered. Immediately after report I checked tha chart because this struck me as very unusual and found that a transcription error had been made when the pt was admitted and the ss insulin had been missed from the hospital ( I am in an LTAC). I noticed on another pt that the sodium tablets on the mar were designated as prn...how odd. This had been there for days on a pt with SIADH and when I checked the order was 2gm tabs po tid. I just want to encourage nurses the check out what may seem odd, even if it has been checked and double checked. It may prevent an error such as this.

good advice above, chimama.

Tulips, I can only imagine how distraught you truly are, and how much you are kicking yourself for this.

Please be encouraged that while we seek to provide only the best of care, mistakes DO happen, and it is FROM these mistakes that we learn to be even more careful. Be ever so grateful that your patient was ok in the end, and use that gratitude to spur you on to higher goals.

Don't kick yourself endlessly... you have better things to do now. (((HUGS)))

first, let me say that everybody makes mistakes, nurses included. even good nurses. even me! i once made an enormous error with heparin. i was changing out all of the patient's iv bags because they were all over 24 hours old. he was on heparin and lidocaine at 1 mg. / minute. he was also on a bunch of other stuff, but those don't matter to the story. about an hour after i changed the drips, he started having ventricular ectopy. so we bolused him with lidocaine and turned up the drip. (this was in the early 90s.) still having ectopy, so we bolused him again and turned up the drip. i'm sure you can see where this is going. the nurse coming on shift didn't follow all of the tubings from the bag to the patient or vice versa, just accepted that my labels were correct. he didn't notice until he had to change the lidocaine bag because it was empty and realized it was heparin. (in the mean time, he had been turning up the "heparin" every six hours because of low ptts).

what separates a good nurse from a bad nurse is not lack of errors; it's how we respond to errors. if you recognize your error, and then report it to the appropriate people rather than lying about it or covering it up, chances are it can be fixed. very few errors cannot be fixed if recognized. (and i ought to know!)

furthermore, it becomes very hard for management to punish you for your error when you're quite obviously punishing yourself. after mike told me about my error, i went straight to the nurse manager and "confessed." (mike had already -- quite correctly -- written it up and turned it in.) i told her how sorry i was, outlined the potential (and thankfully not actual) consequences to the patient, and explained how i thought the error happened and what i planned to do to prevent it from ever happening again. and that's what you need to be thinking about: how did the error happen, and what can you do to prevent it from ever happening again.

ruby (who has made and owned up to quite a few errors in 28 years -- and anyone who tells you they haven't is either oblivious or a damned liar!)

I am writing because I just made a huge mistake and needed to talk about it. I had a patient receive an entire bag of heparin over an hour. The proper people were notified, the correct reversal drugs given, and the patient is fine - thank goodness. I just feel terrible and I'm almost scared to go back to work. The mistake was caused by a mis-communication between two nurses.

Has this happened to anyone? I realize that I'm not the first to make this mistake and I probably won't be the last, but I just feel like such a bad nurse. This is the first big mistake I've ever made. Ugh.

Any words of advice or experience would be appreciated!

Thanks!

Hi

I know that reporting your error was the right thing to do, but you need to realize that you showed great courage and strength of character in doing so. Stop beating yourself up...in the end, it's you who saved the patient. We are human...mistakes will be made...it's the good nurses who do what has to be done to fix them.

RavenC

Your feeling are understandable, they are valid under the circumstances. Any nurse worth their salt would feel bad. The only thing you can do is learn and move on from there.

Yes, it was on a pump, but the other nurse who was supposed to check it did not. I thought she had, and when I asked if the dose was correct, another nurse said yes. However, we were talking in different terms - me in CC's, she in Units.

I've worked in Quality and Risk Management for a number of years in acute care hospitals and have seen lots of statistics on medication errors. Heparin administration errors have been some of the most frequently-occuring at every facility where I've worked.

The question I have is this -- Was the original heparin order actually written by hand or was a pre-printed heparin administration protocol used?

Thanks,

kitty =^..^=