Heparin - Late Rate change error

[NewerNurse01]

Hi, I am looking for constructive feedback regarding a heparin error that I made.

At about a year of practicing as a nurse (8 months on cardiac tele, specifically), I was floated to the step down unit for the first time. I was excited to have higher acuity and focused hard to take care of new-to-me issues with my 3 patients. One patient had bleeding from around her dialysis catheter site (which I reinforced) and was on a heparin drip for a DVT if I remember correctly. This patient went to dialysis which was 3 floors down. On my regular tele floor, we hold meds prior to dialysis, then give appropriate meds upon return. The dialysis nurse, during report, said she would get the PTT that was due while in dialysis. My patient left the unit and I really focused on critically thinking for the other two patients. It was important to me to do a good job on this floor in particular. A while later, I remembered that I needed to check the PTT lab and I obtained the result. Upon return of my patient from dialysis 1hr later, I immediately made the appropriate rate change.

I was written up over this situation because I did not go down to dialysis immediately upon obtaining the PTT result and make the rate change. I had never had to "visit" dialysis and leave my other patients before with exception of the occasional pain narcotic that I had to run to dialysis to administer. Yes, I should have run down to dialysis. Particularly in light of the catheter bleeding which was likely from the heparin administration. But being on a new floor with new conditions and especially on a step down where I would not like to "leave" my other patients (I had worked on a step down previously for 4months where we could NOT leave the unit), and trying to hard to critically think about my patients that were right in front of me, I neglected to consider the patient that was off unit since I was used to not having to tend to a dialysis patient.

I asked other "newer" nurses about the situation and some said they would not have thought to run to dialysis and others said of course I should have known to go.

I appreciate further feedback. Thank you.

[Purple_roses]

It's hard to know what I would have done. It's easy to sit here comfortably, read this story, and know what I would have done, but I know it's harder when you're on the floor. I would have been immediately concerned about the bleeding with a hep drip and would like to think that the best solution would have been to ask my unit manager or charge nurse about how to handle this while the patient was off the floor (formulate the game plan before the patient leaves, because your gut was probably telling you that the hep would need a rate change).

Don't beat yourself up though. It really is hard sometimes to figure out what to do when you have other patients needing your presence.

[LovingPeds, MSN, APRN, NP]

Many things stand out to me. The initial bleeding does definitely. Then, was this value critical? I'm assuming that it was not considering you said you obtained the result. Most hospitals have critical results alerted to the staff in some manner; however, I'm confused on this point because you admit you should have run down to the dialysis floor to make the change. If it was not a critical result and the patient was off the floor, I can see your waiting the one hour for their return to adjust the rate. Second, you mentioned giving report to the dialysis nurse. Report is a transfer of care. You transferred this patient from your care on your (floated) floor to the dialysis nurse's care on her own unit. I'm not saying that the dialysis nurse is at fault for not changing the titration. She may not have even seen the result. Her priority was mostly dialysis, but she is still bares some responsible for this patient as a nurse while he is in her care and is capable of making that titration change on the pump. I'm saying that expecting you to leave your patients and go three floors down to change a rate is like expecting you to go down to surgery to do the similar thing. If the value was critical then I think the dialysis nurse, charge nurse, and the physician should have all been notified immediately so that a plan to rectify the situation could have been developed.

Floating is never easy. I'm curious if you received any orientation to this floor prior to going. I'm also curious as to whether they paired you with a more experienced nurse for that unit in which you could work closely with to help you or if the charge nurse was readily available to answer your questions or checking on your progress. This is not a case where the right thing to have done is readily apparent and that could vary greatly based on hospital/unit policies. I'm sorry that you were written up over this experience. If I were you, I would approach your manager or the other unit's manager and ask what you should have done in this situation as they know the particulars. This will prevent a repeat. Also ask for the differences in unit policy. When you float, you are held to the standards of the other unit. I would also be proactive about suggesting or asking for ways in which this might be prevented in the future such as having the charge follow you more closely or pairing you with a more unit-experienced 'buddy' nurse you can ask questions of or seek assistance from if that charge is unavailable.

[NICU Guy, BSN, RN]

Why didn't you just call the dialysis nurse and inform her of the lab and ask her to make the rate change? Why would you need to leave your other patients and go down 3 floors to push a few buttons on an IV pump. Isn't the dialysis nurse capable of doing it?

[LovingLife123]

If I had seen signs and symptoms of bleeding, which you did, I would have drawn the PTT early and called the doc to see if they wanted the Heparin gtt temporarily stopped. I don't know that I would have waited until it was due because I would have wanted to know right away what was going and why my patient was bleeding. We always have to assess for bleeding with those on Heparin gtts. So to me, the fact the pt was bleeding from the dialysis site would have been a red flag to me.

If the PTT had come back as therapeutic, I don't know at that point exactly what I would have done. I doubt I would have run down to change the rate. I probably would have also waited until they came back. I feel fairly certain that's not something I would be written up either.

[Sour Lemon]

This actually makes me a little angry. The dialysis nurse can monitor labs and give medications ...and if the patient is on her floor under her care than she's the one who should be doing those things. Running around to different units to give narcotics sounds insane to me, too. The only situation I could think of where that might be OK is if their pixis isn't stocked with the med and pharmacy is closed or slow. In that case, I might run down and hand the medication to the other nurse to give.

[Cowboyardee]

1) As asked above, why do you have to physically go? Why is the dialysis unit drawing PTTs but not responsible for acting on them? The dialysis unit has RNs. It would be a pretty weird (and frankly, bad) policy for you to be responsible for physically doing such things while the patient is out of your care and in the care of another RN.

2) How late were you in changing the pump? You made it sound like it was only an hour. Was it much longer?

3) Was the PTT critical? I'm guessing not really, since with most heparin nomograms, a dangerously high PTT value results in turning the drip off, not "adjusting the rate" as you mentioned.

I'd say if the PTT was dangerously high AND there was a substantial delay in addressing it, then you were in the wrong - take it as a learning experience.

If the PTT was not very critical and/or the delay was only an hour or so, then the write up sounds like some nonsense. A quick call to the dialysis unit sounds like it would have been appropriate either way, but it also sounds like your facility has some silly policies about what the dialysis unit is not responsible for.

Who wrote you up? Does their opinion matter? One of the many downsides to being a new nurse is you don't really know when to call BS. FWIW, it's not the write-up you have to worry about, but the people who the write-up goes to. It's what your manager, educator, risk management, etc thinks of the situation that matters.

[Kooky Korky, BSN, RN]

If I had seen blood leaking as you did, I'd have called the doctor and gotten an order to do the lab right then, then followed up accordingly.

This is really a stinking situation. I bet you weren't trained or oriented to the ward you floated to. Why didn't the Dialysis RN follow up on

the lab she drew for the patient who was in her physical care? If you want to write a response to the write-up, you should think about including

these factors - no orientation, D nurse not following through?

But you still, IMHO, should have acted upon the blood leaking when you first saw the patient.

How is the pt?