Is this Med error/bad ?

5 minutes ago, TriciaJ said:

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.

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.

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?

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.

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.

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.

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.

Quote

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.

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.

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.

JKL 33. In my organization the STAT means 20 min to acknowledge the order and 1 hour to carry it out. What is it is yours? JKL 33 I do think way beyond the headline of the original post "Is this med error/bad". Because this nurse that posted it is a prime example of someone who wants to, understands to do the right think for the patient but can not. Like many of us. So I see it as a bigger problem. Because it is not just her making those mistakes as evidenced by another post of "Sour Lemon". Things often get "overlooked". Those things lead to death.

7 hours ago, macawake said:

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?

Dear MacWAke. I will answer your questions one by one.

Incorrect. It is it is not a physician responsibility to call the nurse to remind her of orders. This was not a critical value. Even if it was in most organizations I work it is the nurse that is called first. Is it otherwise in your organization?

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.

The labs are drawn every 6 hours if the PTT level is out of range. Then if the target rage is achieved it is daily. Here there is no an issue of PTT level.

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

Physician said he was "fine". Does not mean it was good for the patient. Physician could have had many reasons to say it was fine. "Fine" is not great. It is not excellent. Would you like to receive "fine care in the hospital"? Or great one or even better excellent?? Honestly?

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.
No. We do not know that the case patient had scheduled procedure. But as experienced nurses we know the reasons for stopping hearing at specific time. Either the med is administered PO and heparin is stopped in which case patient is in hypercoagulopatic state for "only 3,5 hours" or patient is going for the scheduled procedure. Do you know any other reasons it is routinely stopped?
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.

In this case OP knows it is an issue, but wonders how serious because she cares. Why did she miss it ? We do not know? I will ask her.

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.

I am asking so people that read it that have patients life in the hands can put themselves for a moment on the other side of the equation.

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?
OP did not indicate that. I reffed to the next post where another nurse summarized it as things get overlooked. ( I cant seem to find who it was now.) . Yes I have unfortunately worked in the unit where most things get overlooked. It was an LTAC facility where you got 4 vented patients ( trach), plus 2 non vented. Most on isolation. All total care. 1/2 and aid and no charge nurse. RT for 12 patients. Mostly agency nurses working.
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?

I like your questions here very much. I do not know if it is a proven fact. I agree it is hard to prove. Or count. I have been in the healthcare long enough and had variety of experiences to think the numbers might be even higher. Also, I find John Hopkins as a reliable source. Do you? I have seen a lot of of clean cut cases. Surgeons making mistakes, nurses giving wrong medication, or delaying treatment. How do we decide what cause of death was? It is very hard to decide and to know for sure. But if deep in our heart we know what we have seen what should not have happened, are we OK with that?

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 accidentally 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?

Comparing to the aviation is there because it is somewhat similar. People are anxious going to the hospital, also the airplane. The fear of death. It is a sophisticated system they must rely on. The result of their trip depends on how the system is run. The price for mistakes, delays of "overlooking" can be death. The difference, in the airplane quite instant, and clear cause. The hospital less clear. Might be that missed dose of ABT that lead to sepsis and death in 2 weeks. Might be that wrong labeled specimen of blood that lead to mistreatment. It is not very clear. So we can get away with it easier. Big differences: people do not have to travel. They choose to. People get very sick often randomly, when they call 911 they have limited choices of which hospital to go. So they come and are at our mercy.

---

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.

You have hit a big point of non interruption rule and safety. It was great 10 years ago when it was coming to hospitals. It does not seem to stick around though. It was implemented for maybe a year or two then it went back to the old, bad ways. Nurses interrupted, while removing meds, counting meds, administering meds.

With all that replied. Thank you for your comments I enjoy healthy discussion and learning from each other.

Why do the nurses stil keep being interupted even though we know the rule?