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.
One thing that would help maybe is to learn the half life of heparin and why tests are ordered at specific intervals. I was a floor nurse for 40 years and kept an eye out for lab values indicating when the IV dose would need to be increased, decreased or stay the same.
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.
EDIT: I reread it and am confused. So when you got the antixa back did you follow protocol? Because where I work once the antixa comes back if it's not therapeutic (usually the first one is not), pharmacy adjusts it in the MAR discontinuing the old rate which prompts you to scan the bag for the new rate adjustment with a 2nd nurse as witness.
EDIT: I reread it and am confused. So when you got the antixa back did you follow protocol? ...
The problem is that the patient was bolused based upon the anti-Xa level that was drawn prior to the infusion being startedb not the level that should have been drawn 6 hours post infusion initiation.
Drawing a preinfusion anti-Xa level that can take 3 hours to return is problematic and can lead to problems, such as what happened here.
Where I work for patients without concern for a preexisting coagulopathy, we frequently start the heparin without baseline levels.
If the facility is going to draw a baseline level, perhaps they should include a comment in the titration parameters that the infusion is not to be titrated or the patient bolused off of the baseline levels.
The problem is that the patient was bolused based upon the anti-Xa level that was drawn prior to the infusion being startedb not the level that should have been drawn 6 hours post infusion initiation.
Drawing a preinfusion anti-Xa level that can take 3 hours to return is problematic and can lead to problems, such as what happened here.
Where I work for patients without concern for a preexisting coagulopathy, we frequently start the heparin without baseline levels.
If the facility is going to draw a baseline level, perhaps they should include a comment in the titration parameters that the infusion is not to be titrated or the patient bolused off of the baseline levels.
AAah. I think I see. I thought everyone started heparin regardless of baseline levels in critical situations yet held off on further adjustments pending lab results and pharmacy dosing.
Do people still draw baseline PTT when starting a heparin gtt? I thought that was old practice. On my old unit, we never did. They didn't care what your PTT was before starting. We drew one at the 6 hour mark and went from there.
Op, heparin is easily reversible. The fact that lab took 3 hours to result a PTT that is for a heparin gtt is not good and I hope they are written up as well.
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.
I think the labs that were drawn were indeed baseline. The bolus and gtt were given without those results as is normal.
When they returned 3 hours later, no one knew what to do because they weren't supposed to be doing anything right then; those were just their basline labs being returned with some delay.
Not supposed to do anything until the 6 hour mark, which would be a different set of labs.
Obviously I don't know the background situation here, but this sounds like a situation that is way more likely to crop up when all the experience has left the building. Otherwise it would be fairly common/usual knowledge that nothing needed to be done with the baseline lab results.
Our hospital policy states to have an initial anti-Xa drawn before heparin administration
Hailey.B said:
She was started on heparin and the initial bolus and rate were correct.The anti-xa was drawn.
but the policy states: "initial anti-Xa drawn before heparin administration"
Hailey.B said:
She was started on heparin and the initial bolus and rate were correct. The anti-xa was drawn.
This is not what you said the policy was.
JBMmom said:
it sounds like there needs to be more educating of staff in some instances.
JBMmom said:
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.
Right now look for an intensive continuing education program on heparin. A program on floor nurse knowledge (including lab results, dosage and half life) and interventions would satisfy this to add to your evaluation at the end of the year.
Are you in a rural access hospital?
Hailey.B said:
Well the anti-Xa came back 3 hours later (which is ridiculous)
Hailey.B said:
I am anew nurse who has only worked for about 7 months. I work in the ER.
Hailey.B said:
And I'm mad that the MAR did not specifically state to make no adjustments to the dose until after the repeat.
Hailey.B said:
I wish an alert would have popped up or something
Hailey.B said:
I also can't believe that not only did I make the mistake, but the other nurse made it too.
Lottsa blame going around here 1) MAR 2) No alert on the MAR 3) another nurse 4) Your a NEW nurse 5)Lab result slow (which is ridiculous) ( did you call? a heart attack in the ER? checking labs in an emergent situation?)
Buy a book like Gahart on medications and keep it at your work......USE it. Don't depend on "another nurse" "a computer system" "pharmacy" or "lab before you act. You can buy a used one, but not over 5 years old, on Ebay/Amazon
I don't think this was the MARs fault. It isn't going to have the ability to tell you that you need to wait for another lab. From what I gather in your post the baseline lab was mistaken for the 6hr timed lab because it took 3 hrs to result.
The nurse signing off isn't really at fault because it isn't reasonable for them to dig through the chart. What they are signing off is Heparin is at X rate, the lab they are looking at is Y, policy is to do Z with the drip.
The primary nurse should have caught this several times over.
1) She should have noticed that even thought the lab resulted now it was actually for three hours prior (every EMR I have seen puts in lab result times based on when blood actually drawn).
2) She should have caught the fact that it had only been 3 hrs since drip started so it made no sense for that lab result to be her 6 hr timed lab.
3) She should have been surprised by the fact that a patient's result was WNL while on a heparin drip
There was definitely a lack of critical thinking here and effort needs to be made to understand how that happened
Of course all that is irrelevant if both nurses realized it was the baseline draw because then that would demonstrate a profound lack of understanding about how heparin drips work...which would be very worrisome.
Specializes in Nurse Leader specializing in Labor & Delivery.
Mary R said:
I don't think this was the MARs fault. It isn't going to have the ability to tell you that you need to wait for another lab. From what I gather in your post the baseline lab was mistaken for the 6hr timed lab because it took 3 hrs to result.
The nurse signing off isn't really at fault because it isn't reasonable for them to dig through the chart. What they are signing off is Heparin is at X rate, the lab they are looking at is Y, policy is to do Z with the drip.
The primary nurse should have caught this several times over.
1) She should have noticed that even thought the lab resulted now it was actually for three hours prior (every EMR I have seen puts in lab result times based on when blood actually drawn).
2) She should have caught the fact that it had only been 3 hrs since drip started so it made no sense for that lab result to be her 6 hr timed lab.
3) She should have been surprised by the fact that a patient's result was WNL while on a heparin drip
There was definitely a lack of critical thinking here and effort needs to be made to understand how that happened
Of course all that is irrelevant if both nurses realized it was the baseline draw because then that would demonstrate a profound lack of understanding about how heparin drips work...which would be very worrisome.
Great post! Just shows how little I know about this stuff (OB nurse here!). JKL is so right - this is a great example of why we need to keep experienced nurses around!
londonflo
3,002 Posts
One thing that would help maybe is to learn the half life of heparin and why tests are ordered at specific intervals. I was a floor nurse for 40 years and kept an eye out for lab values indicating when the IV dose would need to be increased, decreased or stay the same.
J