Is this Med error/bad ?

Nurses General Nursing

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My pt was on a heparin drip and the Dr discontinued the order at 7:20am. I accidentally overlooked the d/c order. I then noticed it at 10:50 and instantly d/c it. I called the doctor, she was fine with it. But my job does audits on heparin drips etc. is this considered a Med error or very bad? Thank u!

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Specializes in Psych, Corrections, Med-Surg, Ambulatory.

Yes, it's a med error and probably requires an incident report. What do you mean by "very bad"? Was the doctor furious? Did you injure the patient?

Doesn't sound like the patient suffered any ill effects. Take a breath. You said "The doctor was fine with it." Take another breath. The reason you do an incident report is 1. If something comes of it later, Risk Management is already on board. 2. There might have been contributing factors beyond your control that need to be identified. 3. You are a conscientious nurse who holds herself accountable. (Completing an incident report will help establish that and your reputation may come in very handy down the road.)

You will make errors. How you handle those errors after the fact will determine what kind of nurse you are.

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5 minutes ago, TriciaJ said:
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Specializes in ICU, MED Surg, Older Adults,.

Given it is heparin I am very cautious about this kind of medication so it is more serious than less risky medication. It is great that you are thinking about it. It means you care. You will make mistakes as you will go along but nursing is challenging and we are overworked. So just like in emergency prioritize and make sure you do not not miss important things. Meaning things that can kill your patient quick. Here, bleeding during the scheduled procedure. ABC- airway, breathing and circulation. Once you have these secured you will sleep at night. So once you drill in yourself to take care of those important things like their life and safety and hospital allows you for proper staffing and support then you do everything else. Charting after time left taking care of the patients needs. Thats just me.

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On 2/24/2020 at 8:05 PM, Beachgirlxo2017 said:

Hi-

so my pt was on a heparin drip and the Dr discontinued the order at 7:20am. I accidentally over looked the d/c order. I then noticed it at 10:50 and instantly d/c it. I called the doctor, she was fine with it. But my job does audits on heparin drips etc. is this considered a Med error or very bad? Thank u!

That actually doesn't sound unreasonable, to me. If something requires immediate attention, it should be communicated directly. Most things get "overlooked" for a few hours on a busy unit.

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Specializes in ICU, MED Surg, Older Adults,.

According to a recent study by Johns Hopkins, more than 250,000 people in the United States die every year because of medical mistakes, making it the third leading cause of death after heart disease and cancer.Feb 22, 2018

Medical errors third-leading cause of death in America

Some 393 people were killed in civil aviation accidents in the United States in 2018, up 13 percent from the 347 killed the previous year, according to preliminary data from the U.S. National Transportation Safety Board (NTSB).Nov 15, 2019

2018 Data Show Increase in U.S. Aviation Fatalities - Flight ...

https://flightsafety.org › 2018-data-show-increase-in-u-s-aviation-fatalities

We should not be OK with this. "Overlooked" most things. Would you want your mom or dad to be on the busy unit where most things get "overlooked"?

People that come to the hospital trust us with their life. Is this really the best we can do for them? If the airplane mechanic told you he did not have time to check the breaks on the airplane you are about to take because you were too busy would you get on the plane? I am attaching statistics to all nurses, this is how our number look like, this is the people we sign up to take care of. Is this really the best we can do?

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14 minutes ago, Victoria19 said:

According to a recent study by Johns Hopkins, more than 250,000 people in the United States die every year because of medical mistakes, making it the third leading cause of death after heart disease and cancer.Feb 22, 2018

Medical errors third-leading cause of death in America

Some 393 people were killed in civil aviation accidents in the United States in 2018, up 13 percent from the 347 killed the previous year, according to preliminary data from the U.S. National Transportation Safety Board (NTSB).Nov 15, 2019

2018 Data Show Increase in U.S. Aviation Fatalities - Flight ...

https://flightsafety.org › 2018-data-show-increase-in-u-s-aviation-fatalities

We should not be OK with this. "Overlooked" most things. Would you want your mom or dad to be on the busy unit where most things get "overlooked"?

People that come to the hospital trust us with their life. Is this really the best we can do for them? If the airplane mechanic told you he did not have time to check the breaks on the airplane you are about to take because you were too busy would you get on the plane? I am attaching statistics to all nurses, this is how our number look like, this is the people we sign up to take care of. Is this really the best we can do?

That's dramatic. The brakes WILL be "overlooked" while the engine is worked on, assuming there's one mechanic assigned to both tasks. The doctor involved seems to understand that fact.

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1 hour ago, Victoria19 said:

We should not be OK with this. "Overlooked" most things. Would you want your mom or dad to be on the busy unit where most things get "overlooked"?

People that come to the hospital trust us with their life. Is this really the best we can do for them? If the airplane mechanic told you he did not have time to check the breaks on the airplane you are about to take because you were too busy would you get on the plane? I am attaching statistics to all nurses, this is how our number look like, this is the people we sign up to take care of. Is this really the best we can do?

I will try to stay calm here and ask that you do the same. In our various discussions many of us have thought about all of this well beyond headlines (which are disputed, by the way) and analogies that don't remotely compare.

What is the policy for appropriate time-frames to implement routine orders where you work? Routine...not STAT or NOW.

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Specializes in retired LTC.

When admin meds, we all usually hold to that '1 hour before/after' rule. So there's a 3 hour or so window here. We all recognize that heparin is a significant med. So for this instance, I personally, would complete a med error report.

36 minutes ago, JKL33 said:

.... What is the policy for appropriate time-frames to implement routine orders where you work? Routine...not STAT or NOW.

^^^^^ This could make a difference.

Better to just CYA - if someone else wants to trash the error report, so be it.

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3 hours ago, Victoria19 said:

According to a recent study by Johns Hopkins, more than 250,000 people in the United States die every year because of medical mistakes, making it the third leading cause of death after heart disease and cancer.Feb 22, 2018

Medical errors third-leading cause of death in America

Some 393 people were killed in civil aviation accidents in the United States in 2018, up 13 percent from the 347 killed the previous year, according to preliminary data from the U.S. National Transportation Safety Board (NTSB).Nov 15, 2019

2018 Data Show Increase in U.S. Aviation Fatalities - Flight ...

https://flightsafety.org › 2018-data-show-increase-in-u-s-aviation-fatalities

We should not be OK with this. "Overlooked" most things. Would you want your mom or dad to be on the busy unit where most things get "overlooked"?

People that come to the hospital trust us with their life. Is this really the best we can do for them? If the airplane mechanic told you he did not have time to check the breaks on the airplane you are about to take because you were too busy would you get on the plane? I am attaching statistics to all nurses, this is how our number look like, this is the people we sign up to take care of. Is this really the best we can do?

If the patient had a critical value, I assume either the lab or the physician would have made OP aware immediately that the infusion needed to be stopped. Correct?

How often do you check APTT or equivalent at your place of work if the patient is on a heparin drip? Where I work the standard in most scenarios (there are exceptions when labs are drawn more frequently) is every six hours.

OP said that the physician was fine with the delay of 3.5 hours.

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So just like in emergency prioritize and make sure that you do not miss important things. Meaning things that can kill your patient quick. Here, bleeding during the scheduled procedure.

Do we really know that OP’s patient had a scheduled procedure? There are few details in OP’s post and many reasons why a patient could be on a heparin infusion.

If this was me, I’d still make a med error report because I consider them valuable in identifying problems, the possible need for further education/training, or the need for new policies, and can help draw the attention to insufficient staffing levels which might be a factor.

Why are you asking if we’d like to have our relatives cared for in a hospital where ”most things are overlooked”? Of course no one in their right mind would want to be in, or have a loved one hospitalized, in a hospital where most vital things are habitually overlooked.

OP hasn’t indicated that her/his unit is that way. OP was concerned enough about this incident to come here asking for input from other nurses. I’ve never worked somewhere where most things are overlooked. Have you?

I assume you do know that the screaming headline you included isn’t a proven fact? Medical error leading to death isn’t actually counted. It isn’t listed as a cause of death. This can only ever be an estimate. Do patients die from medical mistakes? Unfortunately I’m certain it happens. But how do you decide what the cause of death was?

You seldom have a clear-cut cases where the surgeon operating on a healthy patient with some relatively benign affliction, slips mid-surgery and while attempting to break the fall, waves his or her scalpel-wielding hand around and accidently severs the patient’s aorta with catastophic result.

I’m a bit confused by the post I quoted above. First there’s the headline about medical errors supposedly being the third leading cause of death. It’s directly followed by a paragraph about aviation fatalities? Are you contrasting the two? Since you brought up aviation, do you know about the silent or sterile cockpit rule?

https://en.wikipedia.org/wiki/Sterile_Cockpit_Rule

Healthcare has a lot to learn from the aviation industry and its approach to safety. This rule came about after it was found that pilots who were distracted resulted in several accidents/crashes, and they subsequently implemented the rule forbidding distractions during critical phases of the flight.

Nurses on the other hand, are expected to function safely, efficiently when being responsible for more patients than they ideally should be, and while being constantly interrupted.

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It is a med error, and although it appears your patient did not suffer harm in this instance, Heparin med errors have the potential for being very bad. Heparin is a high risk medication (blood thinner) that is associated with deaths and serious injuries. The elderly are especially vulnerable. Patients have suffered intracranial hemorrhages which have been fatal; the elderly are more disposed to experience this. Serious GI bleeding is another potential complication. The patient can also experience nose bleeds, significant blood in their urine/stool, bleeding at skin puncture sites, etc.

My thoughts are that it would be prudent to be very aware of the medications one's patients are receiving, and to pay especially close attention for order changes for high risk medications.

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Specializes in retired LTC.

Susie2310 - to me, it didn't sound like OP was grossly negligent in missing the heparin order. Sheesh, at 7:20am, she was prob still in report! And docs freq slip in & out without much ado.

So the order wasn't caught early. I'm assuming OP recognized the import of the med as she knew to follow thru.

Yes, it could have been serious and all errors pose that risk.

Y'all do realize that this post was from February. OP never checked back.

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