I Made A Serious Medication Error: Help!

[Hailey.B, BSN, RN]

I am a new nurse who has only worked for about 7 months. I work in the ER. Today I was helping another nurse with a ROSC patient who was having a massive heart attack and was intubated and all the things. She was started on heparin. Our hospital policy states to have an initial anti-Xa drawn before heparin administration, and the level is rechecked 6 hours afterwards, and that determines if the patient needs an additional heparin bolus or a change in the heparin rate. 

She was started on heparin and the initial bolus and rate were correct. The anti-xa was drawn. Two RNs must sign off on heparin.  Well the anti-Xa came back 3 hours later (which is ridiculous) and the MAR was not specific on where to go from there. The nurse and I did not realize or see anywhere in the MAR about having to wait for the repeat anti-Xa before giving a bolus or doing a rate change if needed. Well we gave a heparin bolus, 5100 units. I called pharmacy and that is when we learned we made a huge mistake. I had to let the doctor and charge nurse know. I'm devastated. I can't believe I made such a huge med error. And I'm mad that the MAR did not specifically state to make no adjustments to the dose until after the repeat. Because it stated the policy like how we would make adjustments to the heparin right as we got the anti-Xa result. I wish an alert would have popped up or something stating that we couldn't give the dose, or that pharmacy needs to sign off or something. I also can't believe that not only did I make the mistake, but the other nurse made it too. 

I'm sick to my stomach. The patient was flown out for further treatment of her heart attack. But God I'm so worried that she will bleed out or something and then that big mistake will haunt me knowing that I killed her. I'm so upset with myself. I reported the incident and I expect that my boss will come talk to me and the other nurse about what happened. I just feel so irresponsible and I hate myself for what happened. I need some advice here. I just need someone to reassure me that nurses make medication mistakes and reassure me that I will be okay and not lose my license or go to jail. Just something please. 

[klone, MSN, RN]

I'm so sorry this happened. Med errors are devastating. What you describe is a system error. YOU did not mess up. The system is imperfect, causing ambiguity and confusion. Not just you, but TWO nurses lacked understanding of the process, due to this ambiguity. 

What you CAN do is take this opportunity, and the feelings you're feeling, to fight for a process change, or a policy change, or a policy clarification - something that prevents this from happening to another nurse in the future. 

There are medications that can be given to reverse heparin overdose. You have not killed this patient. Take a breath, know that you are a GOOD and conscientious nurse (based on what you wrote above), and what happened will make you even better, safer, and more careful in the future.

Best wishes, and PLEASE try to let go of the guilt (I say this as a nurse manager). 

[Peachpit]

I agree with klone. Take a deep breath, several if you have to and know you did not kill the patient. Obviously if you and another nurse read the order/protocol the same way then the failure is NOT you. It sounds like there is a lack of process/clear steps on Heparin administration/bolus etc. as klone said.

You have been upfront about what happened, reported it as your should have and will I'm sure discuss it with your boss. BUT YOU are not the issue. 

I know this is awful for you and the other nurse but truly, out of everything bad that happens something good comes from it. Your and the other nurses unintentional error has brought a procedural issue to light and will effect change that will ensure the safety of future patients and nurses alike.

Don't be so hard on yourself. It will be OK.

[Hailey.B, BSN, RN]

Thank you both so much for responding. I feel more relieved like a huge weight has been lifted from my chest. I'm gonna keep breathing, learn from this mistake, and try to move forward. 
 

I do hope my incident report where I made suggestions for change, can influence a change in the system. I will bring it up whenever my manager speaks to me. Our hospital has actually been making mistakes with heparin recently, and I wonder if the unclear MAR instructions is part of the reason. I will definitely make sure to go to pharmacy about any heparin infusions or boluses in the future, and just have the charge RN or a really experienced nurse check over me for any high risk med. 

Thank you again

[JKL33]

So...it does seem like your protocol could be more clear, and I am not wishing to be "that person" (?), but I have a question:

Not sure if I am reading things into your OP, but it seems like your protocol based on what you wrote, is to draw the lab for a baseline and give the initial bolus/start the gtt. Then you are to check the labs again 6 hours later.

If I have understood what you wrote correctly, then the reason your MAR isn't clear what to do when your initial lab (baseline) result returns 3 hours later is because you aren't supposed to be using those results to adjust anything, you aren't supposed to be adjusting anything right then.

(?)

We have all made mistakes. It's an awful feeling and I hope you will receive support in your workplace. I'm glad some of the weight has been lifted by being able to talk about it here.

I bring up the above because it may have something to do with what kinds of changes need to be made/where they need to be made.

???

[Nurse Beth, MSN]

Your patient will not bleed out. Heparin is easily reversible.

[Nurse Beth, MSN]

Can I shamelessly recommend 

Heparin and Nursing Considerations 

[nursej22, MSN, RN]

Your patient will not bleed out. It doesn't cause bleeding, it slows coagulation. And it look up its half-life. It was likely worn off by the time she got to where she was going. Be aware that reversing heparin is tricky, because the reversal agent has some unpleasant side effects.

I once saw a nurse transport a patient on a heparin drip, except they decided it was easier to remove it from the pump for transport. Except they didn't clamp it and the patient got the whole bag in a matter of minutes. 

I've seen the same thing with an insulin drip. That one was scary, but patient remained stable after getting a lot of dextrose. 

[FiremedicMike, BSN, RN, EMT-P]

So you drew your blue top, then started the drip and gave the initial bonus before your labs returned?

Just curious, when they returned, were they normal?  If they were normal, then you didn't overdose the patient at all.  The initial rate/bonus is calculated assuming normal aPTT.

Lesson learned either way, wait until your labs are back before you start heparin. I almost did it the other day trying to help out the other nurse in my zone (not my patient, I just had downtime) and she caught me saying labs weren't back.  Lesson learned for me too..

[KStaleyRN]

The most important thing about this error is that you were upfront and honest about it. Nothing is more dangerous than a nurse who isn't honest about issues in patient care. You'll be a better nurse for it.

Like all the other nurses before me have said: let go of the guilt and know that you can now educate yourself and others, and patients will be safer for it!

[JBMmom, MSN, NP]

I'm a bit late and you've already heard from others so hopefully you're reassured. In the future I think that you are likely to look more closely into the policies regarding more complicated medications, and it sounds like there needs to be more educating of staff in some instances. I hope that you're already feeling better and moved beyond the mistake knowing that you didn't likely cause any harm to the patient, and you've helped identify an area for education that will benefit others. Take care of yourself!

[EdieBrous, BSN, MSN]

Taking an action of any kind can make you feel better and position you for a defense if there is an issue later.  Ask (in writing) to actively participate in the Root Cause Analysis and suggest system changes to prevent reoccurrence.  Additionally, ask if you can present inservices on heparin administration in your facility.  And take CMEs on anticoagulation therapy, medication administration, etc. so you will have those certificates of completion to show you were self-directed in meeting your own learning needs.