INR 5.2 read as 2.5

[Ethio22]

A tired 12 hour shift nurse mistakenly read and put in THE record an INR result of 5.2 as 2.5( read at the turned around anticoag machine).

The Doctor gave order to continue same dose and pt, who also was on levonax inj. Ended up bleeding to death/ICU NOW.

Big, but easly can happen mistake everyone can learn from.

[blondy2061h, MSN, RN]

Why do people respond. If someone comes to allnurses just to ask a stupid question about something they did, a school assignment, or something someone else did IGNORE IT.

This one was too bad not to respond to!

The closest I've seen to this happening in real life is a home glucose meter with calculator style numbers being briefly looked at upside down by a school nurse when it says 95 and them thinking it says 56 and saying "Hey, you feeling okay?" before quickly realizing what happened.

[Davey Do]

blondy2061h said:

The closest I've seen to this happening in real life is a home glucose meter with calculator style numbers being briefly looked at upside down

It's those dang digital numbers!

[Kallie3006, ADN]

Is this research for a new Chicago Med, or Code Black episode?

[Davey Do]

Why do people respond.

This has been both an entertaining and learning experience for me, Bottomed out.

Ethio has sparked quite a lively discussion both here and with my wife Belinda. For example, she ran a lab before becoming a nurse 10+ years ago. Belinda recounted several stories with me, two involving a patient who suffered a brain bleed and another who had an alternating Coumadin dose of 15 and 20 mg!

Being a geriatric psych nurse, I get just enough medical to keep me interested. I believe being in the company of medical nurses who know what they're talking about helps me be a better nurse.

So, Ethio got a like from me for sparking this lively discussion. I'm grateful to those who responded with their witty and informative posts!

[blondy2061h, MSN, RN]

Davey Do said:

It's those dang digital numbers!

Maybe TJC should add upper oriented decimals to their unsafe abbreviations list

[Davey Do]

Ethio22 said:

A tired 12 hour shift nurse mistakenly read and put in THE record an INR result of 5.2 as 2.5...

The Doctor gave order to continue same dose...

A vampire phlebotomist could have surely rectified such a situation!

[Tenebrae, BSN, RN]

They didn't end up dead in ICU?

Dead people end up in the morgue where I come from, the ICU is for the 'tried to be dead but not dead yet people'

[Davey Do]

Tenebrae said:

Dead people end up in the morgue where I come from, the ICU is for the 'tried to be dead but not dead yet people'

[datalore]

[Davey Do]

Davey Do said:

I believe being in the company of medical nurses who know what they're talking about helps me be a better nurse.

While stumbling around on the internet, I happened upon this image:

One of the AN members recently asked a question along the lines of "What makes a good nurse?" A good nurse continues to learn from, among other things, others, their experiences, and their mistakes.

It is my hope that Ethio will not feel negatively toward us as a result our posts, inquisitiveness or good-natured kidding and will learn something from this experience and gain more knowledge.

[Esme12, ASN, BSN, RN]

A tired 12 hour shift nurse mistakenly read and put in THE record an INR result of 5.2 as 2.5( read at the turned around anticoag machine).

The Doctor gave order to continue same dose and pt, who also was on levonax inj. Ended up bleeding to death/ICU NOW.

Big, but easly can happen mistake everyone can learn from.

Again an odd question. Are you a student? Are you in the US?

Of course any mistake is a "big deal". I do not know of any facilities that still hand write lab results but I would not be surprised of there was one out there somewhere.

I can imagine that the patient suffered an episode of life threatening bleeding but patients who have bled to death are not admitted to ICU.

[TruvyNurse]

Did the OP ever return to the conversation??