INR reporting issue

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[h=1]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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Specializes in ICU.

Take responsibility for whatever you did or didn't do, but the nurse giving the Coumadin should have taken the responsibility to check the pt's latest INR.

I'm confused though, you mean that the pt received less Coumadin than s/he should have, right? 1.9 is subtherapeutic for any person needing anticoaugulation therapy with Coumadin.

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Exactly, the patient should have probably been on an increased dose over the weekend.

Thank you for your feedback. I completely own the fact that should have been addressed while I had him on the phone. The fact that it didn't happen after I left though.... I don't know. I just feel like I'm going to be expected to take up responsibility for what happens while I am there AS WELL AS what happens (or doesn't happen) when I'm not there. I could see if it I wrote something on the MAR that made it look as though it had been addressed but I didn't and I'm just not so thrilled to be the fall guy for this one, if it comes to that.

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If it were me, I would tell the UM straight up that while you will take some responsibility for this - it IS the responsibility of the administering nurse to have her proverbial ISH together before she passes pills (you'll want to phrase it more diplomatically) - especially for a high alert medication like Coumadin. If there were an incident, the administering nurse would take the fall before you would. She (the nurse and UM) should take that into consideration before they get lazy.

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Specializes in ICU.

I agree with VANurse. Yes, you forgot to address the INR while addressing the BUN, but the night shift nurse is the one who has final responsibility in this case, unless your facility specifies otherwise in its P&P.

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Thank you. I started this job about 7 or 8 months ago as a brand new nurse fresh out of school but I started on night shift, I've been on days maybe half of that time now, and I am still running into things that are new to me. I'm just really nervous because last week I got called on my day off because I forgot to write up an incident report (did not have anything to do with a medication error or anything I did wrong, something just happened that day) and so that conversation was extremely unpleasant, and I'm just scared of getting a verbal lashing once again, or maybe of management thinking I don't have MY "proverbial ISH" together.

I try to be as through as possible but sometimes I feel like I can't pass ANYTHING onto the next shift, and if I do, it wont be taken care of.

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You can admit that you should have addressed it with the doctor but because you didn't then the nurse after you was responsible. In our mars we pencil in the INR date. I have come in to work and seen that no lab was called that day to complete an INR so I called the doctor myself to get P2 labs done. I would never give Coumadin if I was unsure of the order.

It is easy to kick yourself for missing something but it is a 24 hr facility which means two nurses

after you are responsible as well. Don't be too hard on yourself and don't take all the blame!

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The nurse who passes the med is the one who is ultimately responsible for checking labs that pertain to that med.....what if the INR was 5 and they still gave the patient coumadin?

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Specializes in ICU.

I've been a nurse for >4 years and I still feel like I can't pass anything on to the next shift, that it might not get done, even though I work with extremely talented nurses! As for being nervous about talking to your boss, just admit that you recognize your mistake, and you are taking this as a learning experience- you know this will never happen again!

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Frankly, I wouldn't even be that apologetic about it (as sapphire is suggesting). She should have addressed it when she talked to the MD, but really the *serious* error was done by the next nurse and the subsequent ones.

I've been a nurse for >4 years and I still feel like I can't pass anything on to the next shift, that it might not get done, even though I work with extremely talented nurses! As for being nervous about talking to your boss, just admit that you recognize your mistake, and you are taking this as a learning experience- you know this will never happen again!
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Specializes in ICU.
Frankly, I wouldn't even be that apologetic about it (as sapphire is suggesting). She should have addressed it when she talked to the MD, but really the *serious* error was done by the next nurse and the subsequent ones.

I agree that the other nurse is to blame, but in the interest of staying on the boss's good side, I would just be agreeable and not argue the issue. It is a fine line between merely keeping yourself on the boss's good side and kissing butt (which I do not advocate=P).

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Agreed. I have no problem, as an adult, admitting to exactly what I did and did not do, I just don't want to be a doormat either, and as a new nurse I wasn't exactly certain how much of this is really my fault, or what was expected of me, so I really appreciate everyone taking the time to chime in on this subject.

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