Is this Med error/bad ?

[Beachgirlxo2017]

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!

[Victoria19]

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?

[JKL33]

6 hours ago, Victoria19 said:

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?

With all due respect you did not answer my question, and I emphasized the particular question I was asking for a reason. I work in the ED; everything is STAT or NOW. That's not what we're talking about here.

6 hours ago, Victoria19 said:

I do think way beyond the headline of the original post "Is this med error/bad".

I was referring to your headlines about medical errors being the 3rd leading cause of death.

6 hours ago, Victoria19 said:

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.

I agree with you, but your first post did not at all make your point of view clear.

6 hours ago, Victoria19 said:

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".

I'm not even going back to review because @Sour Lemon did not say that, period.

****

11 hours ago, amoLucia said:

ll do realize that this post was from February. OP never checked back.

I did realize that before I ever posted. I broke my own rule and got sucked in by the ranting and raving anway. ?

[JKL33]

6 hours ago, Victoria19 said:

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?

It is the physician's responsibility to order something STAT or NOW if that's the kind of time frame in which an order is best acted upon. *AND* then there needs to be a reliable process for STAT/NOW and, well, any old orders being able to be known about in a timely manner while the nurse is running around doing 50 other things.

You aren't even understanding what macawake said. S/he is saying that the order likely was not the result of a critical value. It was more likely in the spirit of the doctor saying, "yeah, she can be done with heparin today, she doesn't need that any more." '

6 hours ago, Victoria19 said:

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?

You are talking over people and being completely disingenuous.

What don't you get? This was not a STAT or NOW order. The physician didn't give a crap that the drip was stopped a few hours after the order was written. BECAUSE IT DIDN'T MATTER. If it was something they wanted stopped immediately they would have (hopefully) not written a routine order and then walked away.

Honestly, you'd be better off focusing on making sure your patients' blood pressures are obtained accurately rather than freaking out about this.

However -- what isn't fine about this scenario is that this is an un-closed loop that can be pinned on thousands of different RNs every day.

6 hours ago, Victoria19 said:

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.

There was no specific time! You're making things up so you can keep ranting.

6 hours ago, Victoria19 said:

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.

I resent that you are acting as if we must not care about that. You have no idea what you're talking about.

6 hours ago, Victoria19 said:

But if deep in our heart we know what we have seen what should not have happened, are we OK with that?

No we are not okay with that. Where we disagree is in what should be done about it. Which stems from what the underlying problem is. I believe the underlying problem currently is hospitals themselves and their efficiency processes. Which are in turn motivated by payors. It's a very big problem. Which is why you will never see me here ranting against a nurse when it is clear that something like the OP happens EXACTLY because of poor processes and greedy goals.

If you want to talk about the process of ROUTINE ORDER notification, let's do that.

[macawake, MSN]

9 hours ago, Victoria19 said:

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

Well, thank you for your reply. I too appreciate an exchange of opinions and ideas ? I must tell you though, what I don’t appreciate is being called dear. I feel that terms of endearment between complete strangers are a bit odd, and regardless of whether it’s intended that way, or not (and either consciously or unconsciously on the part of the person using the endearment), it will often be interpreted as condescending and demeaning by the recipient of said endearment. So I think they’re best avoided.

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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.

Why do you believe that you, or anyone else, has to make this point in order for the rest of us to ”get it”? Most nurses aren’t sociopaths. Those who are will not have a ? moment just because someone informs or admonishes them on the internet. The patient’s experience is talked about at length in most nursing educations. Most nurses have been patients themselves or have loved ones who are, or have been patients. It is quite possible you meant no harm, but I just wanted to explain that there is a risk you, or any other poster doing the same, are interpreted as being patronising when you try to show us that we need to look at it from the patient’s perspective.

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Incorrect. It is not a physician responsibility to call the nurse to remind her of her orders. This was not a critical value. Even of it was in most organizations it is the nurse that is called first.

I realize that perhaps I wasn’t as clear as I could have been, but my entire point was that this in all likelihood wasn’t a critical lab (as eveidenced by the physician’s reaction to the delay AND the fact that the changed order/discontinuation didn’t appear to have been communicated in person/directly). And I certainly didn’t say that it’s the physician’s responsibility to remind a nurse to do his or her job. I only said that if it had been urgent the nurse would have been made aware immediately. Either by a call from the lab or from the physician of s/he somehow got the information first.

Quote

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 the 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. It is not very clear. So we can get away with it easier.

My better half is an airline pilot. He once told me when we were discussing safety in our respective professions, that nursing is like him flying the plane, while simultaneously being tasked with serving coffee and tea, cleaning the lavatories and trying to defuse an unruly passenger. He has a point. (As a side note, it’s actually seldom clear cut to investigate the reasons behind aircraft accidents or crashes. They often require lengthy and complex investigations to determine the cause. AND, if the cause is found to be pilot error, they don’t really ”get away with it”).

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Also, I find John Hopkins as a reliable source. Do you?

I definitely do find Johns Hopkins reliable. That doesn’t mean I won’t exercise critical thinking though, and just take everything they present as gospel. I don’t think it’s proven that medical errors is the third most common cause of death. Again, what did they really measure?

One other thing I think one needs to keep in mind when one says that medical errors kill people, is how many of the people who died would have survived without any medical treatment at all during the life time? I’m not saying this to minimize the impact of medical mistakes, only to offer perspective. Decreasing the number of preventable medical mistakes/adverse outcomes, should be and is high on our collective list of priorities.

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Why do the nurse still keep being interupted even though we know the rule?

I don’t know the full answer to that. I can identify two factors though, that I think are at least partially responsible. One is financial. Many healthcare facilities aren’t adequately staffed. The other is hierarchy/respect/tradition/roles. I think that nurses should stop being such people-pleasers. Say no. Set boundaries. I don’t work as a floor nurse, but when I did I was quite firm with people interrupting me. As a consequence I was interrupted much less frequently than most of my coworkers.

[JadedCPN, BSN, RN]

1 hour ago, macawake said:

I think that nurses should stop being such people-pleasers. Say no. Set boundaries. I don’t work as a floor nurse, but when I did I was quite firm with people interrupting me. As a consequence I was interrupted much less frequently than many of my coworkers.

This, absolutely. Part of my admission/transfer spiel always has and always will include three important times: morning shift change, 0900 med pass, and night shift change. I make it very clear to the patients and their family that when at all possible, nursing should not be interrupted at this time due to safety reasons. I have no problem telling a pt/family that they can't get their IV wrapped for a shower at 1900, it needs to be 1800 or 2000. I have no problems telling a family that I will get whatever their non-urgent request may be after I safely finish my 0900 med pass.

[amoLucia]

macawake - maybe just my interpretation but I don't think other poster meant anything endearing or condescending. More like the common opening on correspondence as in 'Dear Sir:' or 'Dear Occupant:' JMHO

To all others - this has been interesting reading. I think we've gone the full gamut from simple error to deeper interpretations. One thing - don't know how others feel about this, but I found all the quotings and split-responses to be confusing to follow. Generally, interesting, but hard to follow.

[Victoria19]

On 2/24/2020 at 11:05 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!

JKL33. There was no STAT or NOW in this initial post. So you brought up a question about it. So I answered. What did I miss about your question?

The order was to stop at 7:20 am, it was not done till 10:50. We all know that is the fact here. Now the reasons why it did not happened, might vary. We all agree it was not good for the patient but not end of the world but enough for us/ caring/ loving/ compassionate/ dedicated nurses to feel about about it and talk about it.

So let's vote, take a guess. Why this nurse did not get a chance to stop this heparin as ordered? What could have gone wrong?

I do not like this this statement you made however very much:

"You aren't even understanding what macawake said. S/he is saying that the order likely was not the result of a critical value. It was more likely in the spirit of the doctor saying, "yeah, she can be done with heparin today, she doesn't need that any more." I do not believe it was any kind of "yeah". It is medicine, these are life matter's this is high risk medication and such a cavalier attitude is never good for the patient". Orders of physicians are not in the spirit of anything. This is science of how pharmacokinetic and pharmacodynamics. I understand the order was not a result of a critical value. It does not mean it should not be carried out in the timely fashion owed to this kind of medication infusing in human body. We are not talking about Tylenol being given 3 hours late. There would be no conversation here. The OP , original post would not feel worried enough to post it. I think.

"There was no specific time! You're making things up so you can keep ranting." The specific time to stop was 7:20am JLK33.

10 hours ago, JKL33 said:

I resent that you are acting as if we must not care about that. You have no idea what you're talking about.

I am not sure what you meant by it. Please clarify.

Also your last paragraph. So you think insurance companies are to blame for nurse not picking up the heparin order? Please elaborate how so? Also, the process of orders is to blame. Give me an example of the process that is to blame.

9 hours ago, macawake said:

and ideas ? I must tell you though, what I don’t appreciate is being called dear. I feel that terms of endearment between complete strangers are a bit odd, and regardless of whether it’s intended that way, or not (and either consciously or unconsciously on the part of the person using the endearment), it will often be interpreted as condescending and demeaning by the recipient of said endearment. So I think they’re best avoided.

macawake. I am sorry if I offended you by addressing you dear. It is also a form of being warm showing endearment to someone you are trying to have positive opening of the conversation with. I also personally feel all the nurses are DEAR. For doing what they are doing. Clearly I am wrong about you if this offends you. Interesting that you are bringing up the sociopath in your next paragraph.... Hmm.... Makes me wonder. ...

9 hours ago, macawake said:

I only said that if it had been urgent the nurse would have been made aware immediately.

Nurse was made aware by written order.

Interesting macawake that your husband is a pilot so you can really compare first hand. I am sure you know the pilots have limitations and are constantly monitored to assure they are at their best to fly the plane. Nurses work night shift. Take care of kids at home, while "napping" then come to take care of patients in ICU. Mistakes are bound to happen. Nurses take care of sick people but do not have health insurance on their own. If I hospitals would keep us more accountable we would start keeping them more accountable. So shhh, do not ask do not tell....

9 hours ago, macawake said:

definitely do find Johns Hopkins reliable. That doesn’t mean I won’t exercise critical thinking though, and just take everything they present as gospel.

Please do a detail research if you are disproving JH numbers. Share with us better knowledge that they are sharing.

9 hours ago, macawake said:

I can identify two factors though, that I think are at least partially responsible. One is financial. Many healthcare facilities aren’t adequately staffed. The other is hierarchy/respect/tradition/roles. I think that nurses should stop being such people-pleasers. Say no. Set boundaries. I don’t work as a floor

I think you nailed it here. Do you know how much hospital CEO makes? Nurses are giving, sweet people pleases does play a big role.

3 hours ago, amoLucia said:

To all others - this has been interesting reading. I think we've gone the full gamut from simple error to deeper interpretations. One thing - don't know how others feel about this, but I found all the quotings and split-responses to be confusing to follow. Generally, interesting, but hard to follow.

I agree is hard to follow. I am getting a hand of it. Perhaps we can make some suggestions to this website to make it easier to follow and post.

If we could answer each individual person instead of having quote and copy paste. It would be so smooth. Yet we are going through some interesting, valid concerns for nursing filed plus working out some personal feelings. Truly enjoyable discussion.

[JKL33]

23 minutes ago, Victoria19 said:

JKL33. There was no STAT or NOW in this initial post. So you brought up a question about it. So I answered. What did I miss about your question?

I asked a very clear question specifically noting that I was NOT asking about STAT time frames. Here it is again (even more emphasis added):

On 8/16/2020 at 4:51 PM, JKL33 said:

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

You then answered and told me what is expected for STAT orders at your place.

31 minutes ago, Victoria19 said:

So let's vote, take a guess. Why this nurse did not get a chance to stop this heparin as ordered? What could have gone wrong?

My "vote" is because s/he was doing other things and didn't see the order.

31 minutes ago, Victoria19 said:

I do not believe it was any kind of "yeah". It is medicine, these are life matter's this is high risk medication and such a cavalier attitude is never good for the patient".

I am sorry, really, I do not wish to carry on in a rude manner. But you are writing as if you have a knowledge deficit. YES, I 100% guarantee you that not every doctor's order is written in the spirit of do-it-now-this-is-life-or-death. Even stopping a heparin drip. That you don't even seem to conceive of this possibility is strange to say the least. I am trying to use a large dose of restraint here because I can't fathom that an RN wouldn't understand the very routine stops, starts and changes as some patients' plans of care progress. I will give you the benefit of the doubt with an example:

Patient was on heparin gtt while achieving therapeutic INR for new coumadin dosing. Today's labs show a therapeutic INR, so when the doctor comes around they note the labs and decide that it's safe to stop the heparin drip today. They therefore write an order that says d/c heparin gtt.

That is totally different than "Patient's bleeding out from every orifice, stop the heparin STAT."

40 minutes ago, Victoria19 said:

We are not talking about Tylenol being given 3 hours late.

See you are reacting based on the idea of heparin itself.

Please also note that whether or not something is important (high priority) has to do with the individual patient. Tylenol may be very important if it has been being given to someone whose liver is now not functioning up to par. And it would be very high priority for that patient to not receive any more Tylenol. Likewise this heparin discontinuation does not seem like anything near an immediate life or death order.

This is why I say you need to think things through. You are reacting based on this "because heparin" thing.

The bottom line is that no one has yet suggested a time frame (or shared a real life policy) for how quickly RNs should implement routine orders. I also googled the matter every which way and have come up pretty empty.

ALL routine orders should be implemented as soon as possible. Other matters WILL, guaranteed, take priority over routine orders. Regularly.

What is needed here is a standard expectation. I suspect there isn't one because that makes it very convenient to point the finger at individual RNs over and over and over ad nauseam day after day in places all across the country.

[Sour Lemon]

1 hour ago, JKL33 said:

I asked a very clear question specifically noting that I was NOT asking about STAT time frames. Here it is again (even more emphasis added):

You then answered and told me what is expected for STAT orders at your place.

My "vote" is because s/he was doing other things and didn't see the order.

I am sorry, really, I do not wish to carry on in a rude manner. But you are writing as if you have a knowledge deficit. YES, I 100% guarantee you that not every doctor's order is written in the spirit of do-it-now-this-is-life-or-death. Even stopping a heparin drip. That you don't even seem to conceive of this possibility is strange to say the least. I am trying to use a large dose of restraint here because I can't fathom that an RN wouldn't understand the very routine stops, starts and changes as some patients' plans of care progress. I will give you the benefit of the doubt with an example:

Patient was on heparin gtt while achieving therapeutic INR for new coumadin dosing. Today's labs show a therapeutic INR, so when the doctor comes around they note the labs and decide that it's safe to stop the heparin drip today. They therefore write an order that says d/c heparin gtt.

That is totally different than "Patient's bleeding out from every orifice, stop the heparin STAT."

See you are reacting based on the idea of heparin itself.

Please also note that whether or not something is important (high priority) has to do with the individual patient. Tylenol may be very important if it has been being given to someone whose liver is now not functioning up to par. And it would be very high priority for that patient to not receive any more Tylenol. Likewise this heparin discontinuation does not seem like anything near an immediate life or death order.

This is why I say you need to think things through. You are reacting based on this "because heparin" thing.

The bottom line is that no one has yet suggested a time frame (or shared a real life policy) for how quickly RNs should implement routine orders. I also googled the matter every which way and have come up pretty empty.

ALL routine orders should be implemented as soon as possible. Other matters WILL, guaranteed, take priority over routine orders. Regularly.

What is needed here is a standard expectation. I suspect there isn't one because that makes it very convenient to point the finger at individual RNs over and over and over ad nauseam day after day in places all across the country.

You have a lot more patience than I do. I tend to respond back one time, then go make some nachos and see what else is going on (since throwing an emoji vase at other users is not an option).

[Susie2310]

1 hour ago, JKL33 said:

The bottom line is that no one has yet suggested a time frame (or shared a real life policy) for how quickly RNs should implement routine orders. I also googled the matter every which way and have come up pretty empty.

ALL routine orders should be implemented as soon as possible. Other matters WILL, guaranteed, take priority over routine orders. Regularly.

What is needed here is a standard expectation. I suspect there isn't one because that makes it very convenient to point the finger at individual RNs over and over and over ad nauseam day after day in places all across the country.

For a time frame for implementation of routine orders I think it would be important to prioritize more highly time sensitive routine orders over less time sensitive routine orders for the individual patient. Heparin is a high risk med, and we also don't know the patient's most recent aPTT, or their clinical status, and I think we've all agreed that it would have been best if the order change had been caught timely and the Heparin D/C'd timely, so I believe the order falls into the more highly time sensitive category.

The OP said that he/she didn't see that the Heparin drip had been D/C'd, so to me what's important is to know what meds one's patients are currently receiving, and to be aware of high risk meds the patient is receiving, and to pay close attention for order changes, especially for high risk meds. One can look at how one is prioritizing those "other matters" early in the shift, and see if some should be given a lesser priority than checking for med order changes (especially for high risk medications) and for implementing those orders as a priority.

[JKL33]

15 minutes ago, Susie2310 said:

so I believe the order falls into the more highly time sensitive category.

I will entertain that idea, but that rationale would demand then, that every heparin order be written as a STAT or NOW, and there would be a very proven tool/protocol/process for notifying floor nurses of such orders. Since it's a very sensitive matter.

25 minutes ago, Susie2310 said:

so to me what's important is to know what meds one's patients are currently receiving, and to be aware of high risk meds the patient is receiving, and to pay close attention for order changes, especially for high risk meds.

Okay. Will entertain this as well. What are the specifics of carrying this out? There are 6 patients. Every one of them likely has some medication that is arguably of higher priority in their plan of care, whether that be heparin or antibiotics or their insulin or xyz. So, nurses should check their orders every [how often?] in case there is an order that, although it is written as a routine order, is actually a higher priority than every other thing they are doing?

26 minutes ago, Susie2310 said:

One can look at how one is prioritizing those "other matters" early in the shift, and see if some should be given a lesser priority than checking for med order changes (especially for high risk medications) and for implementing those orders as a priority.

It is a given that some things will be able to be de-prioritized (or, prioritized) early in the shift. Nurses are specifically trained to do this. But "always knowing about routine orders that turn out to involve sensitive medications" is not a singular thing that can be prioritized in the way you are suggesting.

What you are saying is that if there is a routine order that turns out to involve a sensitive medication then the nurse should automatically know about it sooner than s/he otherwise would have because it is an order that involves a sensitive medication. That is circular and what is missing is the process to actually achieve the awareness/knowledge right away.

I think you are looking at this from a rear-view perspective and coming up with a suggestion that doesn't quite work the same when looking forward. But I am willing to try to understand how you would make this work.

[Victoria19]

3 hours ago, Sour Lemon said:

My "vote" is because s/he was doing other things and didn't see the order.

I like your vote. It is very general but it contains a lot of truth.

3 hours ago, Sour Lemon said:

I am sorry, really, I do not wish to carry on in a rude manner. But you are writing as if you have a knowledge deficit.

Maybe I do have knowledge deficit. I am alway open to learning new things. Thus, I am spending time discussing things that otherwise might not be a good idea to discuss at workplace. I agree this clearly was not STAT order. So we are on the same page. I agree there is not specific time written in stone. But it is written in stone that this medication is high risk. (please do not read into my metaphor). However, to be completely honest. 100%. How long would you like the nurse to take to stop the heparin order on your loved one?? ( Likely elderly) How long would you be OK with the nurse stopping IVF? Maybe, that is the time frame we should aim for as Registered Nurses Professionals? What do you think?

Thank you for sharing and example to model what is on your mind. My knowledge about heparin drip involves working 7 years in ICU/CCU/CTICU settings. So I believe I have a grasp on how heparin is ordered and when it needs to be stopped. As far as therapeutic levels go, we usually "bridge" the patient to Coumadin. Meaning first give PO. Wait for few hours then stop the drip. If the drip is stopped without prior order of Comandin with instructions to stop the drip after few hours then it is due to the fact the patient is scheduled for the procedure and they need the time to thicken the blood so they do not bleed to death during the procedure.

3 hours ago, Sour Lemon said:

This is why I say you need to think things through. You are reacting based on this "because heparin" thing.

I am reacting because the original nurse OP was concerned enough to post this question. I am reacting because there are many, many nurses that despite of best intentions and working without bathroom and food go home and worry if they have caused harm. Because there are many nurses that suffer quietly or not even realize they do and that leads to burn out. Then nurses leaving profession or at least bedside and reaching out for substances. I know this is far from the example of the heparin but not that far.

What kind of bedside nursing do you do by the way? I am sorry if I missed that in your posts.

Thank you for doing research about the time frame recommended for med administration. Also, thank you for suggesting more clear expectations to protect the nurses. Sadly, it is a common thing in 2 states I have practiced as an RN: "If in doubt, blame the nurse..."

3 hours ago, Susie2310 said:

The OP said that he/she didn't see that the Heparin drip had been D/C'd, so to me what's important is to know what meds one's patients are currently receiving, and to be aware of high risk meds the patient is receiving, and to pay close attention for order changes, especially for high risk meds. One can look at how one is prioritizing those "other matters" early in the shift, and see if some should be given a lesser priority than checking for med order changes (especially for high risk medications) and for implementing those orders as a priority.

I agree Susie2310 with every word you have said. If I have time I do learn of the meds the patient is on and find out what the goal is for some of them. Like heparin or number of Vancomicin doses in the renal patient. Also, wait for the results of the digoxin level before giving 6m dose.

2 hours ago, JKL33 said:

3 hours ago, Susie2310 said:

so I believe the order falls into the more highly time sensitive category.

I will entertain that idea, but that rationale would demand then, that every heparin order be written as a STAT or NOW, and there would be a very proven tool/protocol/process for notifying floor nurses of such orders. Since it's a very sensitive matter.

JKL33 it is not every heparin order that is STAT. It is the judgment of the nurse and receiving detailed report to know that the heparin might need to be stopped soon for possible procedure in AM or starting oral theraphy. is it part of your hand off report?

3 hours ago, Sour Lemon said:

You have a lot more patience than I do.

Thanks Sour Lemon. Feels like it is only one thing that you have said to me so far. I will take it. I do have quite a bit of patience. It was not always like that though.

2 hours ago, JKL33 said:

That is circular and what is missing is the process to actually achieve the awareness/knowledge right away.

JLK33, there could be another alert that high alert medication is requiring of discontinuation. That is one solution. If you gave it to your organization how long would it take them to implement it?? Would they ever do that?.

I personally think that solution is knowing your patients, getting detailed report and understanding what is going on with your patients and how what were are doing to them at the hospital is affecting them. I ask a lot of questions during the report and IfI do not get answer and know it is important to know I will search the chart of ask quick question of the MD. "Hey, this patient is supposed to have toe amputated tomorrow. Do we stop his heparin drip at any point?" So, awarness begins when you are taking a report. It is hard in the first years of nursing. Very hard. But questioning like OP did and thinking about this like we do helps for the future.

2 hours ago, JKL33 said:

So, nurses should check their orders every [how often?] in case there is an order that, although it is written as a routine order, is actually a higher priority than every other thing they are doing?

Nurses check their orders accordingly to the hospital , unit policy. They will be held to that standard in the court. Check your hospital policy. Besides policy there is common sense. But to be legally protected on med -surg it is every 2 hours for example. In ICU every hour.