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Discussion

INR reporting issue

Hey, I just wanted to get something off my chest, and get a little feedback because something happened this week that has never happened to be before and as a newer nurse I'm not sure how I should handle it if I get called this week about it.

I work weekends 6a-6p, during my shift saturday I get a call from the lab on one of my patients with a critical BUN. They said they were going to fax it over. An hour passes, maybe two, I still don't have this lab so I call them again and ask them to fax it. Then I wait some more. And then I wait and wait. I go over to the fax machine, BAM, no paper, so I put some in, and then I did get ONE copy (so I know they faxed it once, regardless of the paper situation)

Anyways, by this time its about the end of my shift, I'm passing meds and finishing up, I write the orders pertaining to the BUN, and hand the lab off to the night shift nurse. Well, I didn't address the INR with the doctor. It was 1.9.

Typically what I should have done was address the INR and put something on the coumadin flow sheet in the mar. I didn't write ANYTHING on the flow sheet in the mar but I guess the night shift gave the coumadin anyway on saturday evening and sunday evening, THEN, she turns around and calls me at about 5AM monday morning asking me about this INR that is technically out of range.

My first instinct is to complusively apologize for everything, all the time, no matter what, and take responsibility for everything but I cannot help but feel like this is not my fault entirely. I told this nurse exactly what I had addressed with the doctor, I handed the labs off to her, I wrote NOTHING on the flow sheet about it and frankly, I'm shocked she gave it anyway without calling the doctor for new orders. I feel like what really happened is she probably just gave the pills in the cart and didn't even look at the mars.

I don't know. My unit manager is extremely effective, and a little bit scary. I don't know what to do. Do I stand up for myself and tell her that night shift needed to have called the doctor and that I did not sign off on the out of range INR, or do I just take it on the chin and say I am the only one who had a responsibility to call the doctor and take the fall for a medication error?

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    In my opinion both nurses are responsible for getting the INR addressed. If you weren't able to get it done, pass it on. The night nurse should have called the doctor before giving the coumadin. I've learned that lesson.

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    • Experts

    At the facility where I work, Coumadin is administered at 7:00pm per policy. The nurse who gives the Coumadin is responsible for knowing the most recent INR prior to administering it to the patient(s).

    All shifts are accountable for addressing the slightly out-of-range INR, but the evening shift nurse who simply gave the Coumadin without looking into the matter seems more at fault in my opinion.

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    I agree with the Commuter. Therapeutic range is between 2-3 , just a small difference . Nevertheless, the dosage should have been addressed either through your coumadin dosing protocol or doctor's order. The PM shift nurse who gave a high risk medication such as Coumadin should check INR result. That is why there is a flow sheet. Now, with regards to getting a high alert result, your laboratory cannot give you the numbers over the phone? I mean, there is a reason why they are calling you- to report an abnormal result which could direct the care or treatment of the patient. You mentioned that your manager is very effective, right? I suggest , go to him/ her and review your policy on taking high alert results from Lab and also your policy on administering High risk meds like Coumadin. Im pretty sure your company has a policy on both. Good luck to you.

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    A patient of mine returned from dialysis after 11pm. I am to give the evening meds (20:00 meds) at that time. Coumadin is one of them. The lab result did not come in until 11:00 pm. The INR was below therapeutic, therefore I gave the Coumadin without a new order, knowing that the new order would be a higher dose if anything. I felt it was not necessary to call the MD that late at night, that it could wait until the morning. What do you think?

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