Is this Med error/bad ?

Sour Lemon · Aug 18, 2020

Victoria19, you have "quoted" me three times, but with things that I did not actually say. And the one quote that was actually mine was in response to JKL33.

...just putting that out there.

cmurra6745, ADN · Aug 18, 2020

On 2/24/2020 at 11:05 PM, Beachgirlxo2017 said:
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!

ideal thing would be draw a pt/ptt/inr just in case and quality track the mistake so in the future they can educate about the mistake

macawake, MSN · Aug 18, 2020

10 hours ago, Victoria19 said:
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. ...

I’m not sure I understand what you thought was interesting... Perhaps you can elaborate?

The reason for my using the word sociopath is that they would need the concept of empathy explained to them as they don’t naturally feel it. Most people, nurses included, don’t need to have empathy explained to them. That’s why I said there is a risk that it comes off as patronising when a poster attempts to do that to a bunch of nurses on a forum.

I’ll take you word regarding your intention when using an endearment. I’m not massively offended over here, so no harm done. I just don’t think it’s appropriate when talking to another adult, especially one you don’t know. But that might just be me.

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Nurse was made aware by written order.

Well, yes... You and I don’t seem to be communicating very well... Being made aware immediately is not the same as a physician entering an order, but not communicating that they changed an existing order or added a new one. I assume they would do exactly that (communicate directly) if it was an urgent matter. How often is a nurse supposed to check on each patients’ medications orders just in case something has changed (but hasn’t been verbally communicated). Once per shift? Twice per shift? Once an hour? Every ten minutes?

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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 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....

I’m Scandinavian and we have universal healthcare. I find it truly sick that a nurse, or any other person, can be in a position where they don’t have coverage for needed preventative and medical care. But that’s a topic for another thread ?

I don’t understand what you mean by hospitals starting to keep us more accountable? In what way? Fines? Jail? Revocation of licences? Tar & feathers? ( <—not entirely serious about that last one). Seriously though, I already feel like I’m accountable for the mistakes I might make. Both legally and morally.

I believe that a punitive approach regarding mistakes made in healthcare risks people hiding the mistakes they make. They’re afraid to come forward when the consequences might be loss of employment/license. In cases of outright malpractice I definitely think that a nurse or physician should face severe consequences. However the majority of mistakes made don’t fall into that category, and there are often a number of contributing factors in play, and I personally feel that they are better countered by identifying and analyzing the root cause and implement changes to prevent the same mistakes happening again.

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

That article has been widely criticized on methodology since it was published. It’s also been used by anti-vaxxers, pseudoscience, alternative medicine proponents and the like. It’s also been used by for example Russia as an anti-American propaganda tool. Look at those Americans, killing their own by the hundreds of thousands... That’s the main reason why I’m bothered by seeing it linked with screaming font on a nursing site. I think the topic requires a bit more nuance.

It’s somehow morphed into a solid fact when all it ever was, was an extrapolation based on a few studies. The following links explain much of how I feel about the publication, but they express it better. (And they’re have done all the work, so I don’t have to ?).

https://www.bmj.com/content/353/bmj.i2139/rr-54

https://www.amjmed.com/article/S0002-9343(16)30705-7/pdf

https://sciencebasedmedicine.org/are-medical-errors-really-the-third-most-common-cause-of-death-in-the-u-s/

https://sciencebasedmedicine.org/are-medical-errors-really-the-third-most-common-cause-of-death-in-the-u-s-2019-edition/

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Truly enjoyable discussion.

Agreed ?

macawake, MSN · Aug 18, 2020

9 hours ago, JKL33 said:
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.
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.
ALL routine orders should be implemented as soon as possible. Other matters WILL, guaranteed, take priority over routine orders. Regularly.

I agree 100% with what you 100% guarantee.

(I’ve edited/deleted parts of your post that I quoted. That’s not because I don’t agree with all of it. I do. I just thought that the parts I left very clearly illustrates my own thought process from a to z here. So I hope you don’t mind that I took some liberties ?).

macawake, MSN · Aug 18, 2020

8 hours ago, JKL33 said:
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.
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?
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.

I find myself agreeing with all your posts here ?? The part I bolded is in my opinion what it boils down to.

To me this discussion has an element of nursing in an ideal world vs nursing in the real world.

Tweety, BSN, RN · Aug 18, 2020

Great discussion. I suppose it would depend the if it was being d/c'd because the therapy was finished or because the PTT/PT/INR was too high. Heparin doesn't have a long half life so as the doc indicated it wasn't a big deal and didn't give any more orders. You did the right thing there.

That being said, you found the order, you stopped it and you notified the MD. You're not minimizing and asking questions show you care and were bothered by it.

What else did you learn? What can you do differently to prevent this moving forward.

The reality is that in my day, and I can't only speak for myself, new orders sometimes don't get implemented right away, or even seen right away.

JadedCPN, BSN, RN · Aug 18, 2020

I'm really confused how several posters are jumping to all these conclusions that the patient is going to a procedure or has high lab values when all the OP said was she received an order to stop a drip at 0720 which was accidentally overlooked and didn't stop it until 1050.

macawake, MSN · Aug 18, 2020

47 minutes ago, JadedCPN said:
I'm really confused how several posters are jumping to all these conclusions that the patient is going to a procedure or has high lab values when all the OP said was she received an order to stop a drip at 0720 which was accidentally overlooked and didn't stop it until 1050.

I know. That’s puzzled me all along. It’s definitely been an interesting thread, but a wee bit strange ? There’s literally nothing in OP’s (who’s long gone from this thread) short post that indicates that.

Sounding a bit like a broken record here, but if this had been a case of a dangerously prolonged aPTT or severe thrombocytopenia (heparin-induced) this wouldn’t have unfolded the way OP told it. There’s no denying that heparin is a medication that warrants careful monitoring, but this thread in my opinion took a surprisingly dramatic and alarmist turn, for something that I personally didn’t get extremely concerned about.

JKL33 · Aug 18, 2020

10 hours ago, Victoria19 said:
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)

It would depend almost entirely on my loved one's situation and the direct importance of the order to my loved one's situation.

10 hours ago, Victoria19 said:
How long would you be OK with the nurse stopping IVF?

Ditto the answer given directly above.

I am not fond of labeling things like this good/bad or right/wrong completely devoid of context.

10 hours ago, Victoria19 said:
So I believe I have a grasp on how heparin is ordered and when it needs to be stopped.

I trust that you are familiar with how heparin is commonly used on your unit.

10 hours ago, Victoria19 said:
What kind of bedside nursing do you do by the way? I am sorry if I missed that in your posts.

Answer:

On 8/17/2020 at 8:24 AM, JKL33 said:
I work in the ED [...]

10 hours ago, Victoria19 said:
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?.

If they had already gotten out of their silos, reached out and collaborated to gather input from their stakeholders in order to decide whether or not this was best practice, they might do something, like set up a meeting to discuss whether they should form a focus group. I would estimate that it would take on the order of many months to possibly years or never.

10 hours ago, Victoria19 said:
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.

I share your concerns. I suppose I am not understanding the tone you conveyed in your first post and some subsequent posts. My first reaction is not horror at the OP scenario. My reaction is pretty neutral. I'm more curious about what people think it is reasonable to expect. I want some details of what should be de-prioritized so that an RN will always and automatically be able to know about things done without their knowledge while they are busy doing innumerable other things.

10 hours ago, Victoria19 said:
JKL33 it is not every heparin order that is STAT.

I think it might be best if we just move past this particular point I was hoping to make.

10 hours ago, Victoria19 said:
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.

You are the second person who has stated this obvious now, and I think we can all agree. This is basic nursing. It is insulting to suggest that this is the main reason that RNs do not provide ideal care in every circumstance.

I still haven't made the connection in how "knowing your patients" enables you to have ESP about what orders were written about highly sensitive meds while you are busy in a 1:5 or 1:6 floor assignment. Somewhere there is a time frame within which it would be considered reasonable good practice to discover and act upon such an order. I'm curious what that time frame is. I don't have the answer. Overall, it seems that this delay strikes some people as being worse because it involves heparin. So how often should nurses look to make sure no one has quietly changed the patient's heparin orders? And what about all the other other medications that are important for other patients? How often should the RN check to see if someone quietly changed one of those orders? Or any order?

10 hours ago, Victoria19 said:
Nurses check their orders accordingly to the hospital , unit policy. They will be held to that standard in the court. Check your hospital policy.

I'm waiting to hear what people's policies are for checking to see if there are any routine orders that just so happen to be highly sensitive.

I don't need to check my policy, every single thing in my department happens as if the whole place were on fire. In fact, like many EDs we have STAT and, unofficially (but out of necessity), "really STAT."

JadedCPN, BSN, RN · Aug 18, 2020

1 hour ago, JKL33 said:
I don't need to check my policy, every single thing in my department happens as if the whole place were on fire. In fact, like many EDs we have STAT and, unofficially (but out of necessity), "really STAT."

I float to the ED enough to laugh way too hard at this, so true.

It doesn't matter if it was heparin or a normal saline KVO infusion really; The only "error" that was made here was OP admitted they "overlooked" the DC order...which was placed at shift change, at the beginning of a shift, at 7:20, which is horrible timing in general.

In my personal experience, if an order needs to be carried out right away, the ordering provider reaches out to the nurse or charge nurse to say "hey just a heads up, I put this order in stat if we can get to it." Most providers are aware of shift change time and are aware that a lot is going on during that time. This would be a great root cause analysis situation to see how this isn't the nurse's fault but rather a series of system issues across the board that just happened to align at the wrong time.

Susie2310 · Aug 18, 2020

2 hours ago, JKL33 said:
I share your concerns. I suppose I am not understanding the tone you conveyed in your first post and some subsequent posts. My first reaction is not horror at the OP scenario. My reaction is pretty neutral. I'm more curious about what people think it is reasonable to expect. I want some details of what should be de-prioritized so that an RN will always and automatically be able to know about things done without their knowledge while they are busy doing innumerable other things.
The OP said that they overlooked the order to D/C the Heparin drip. I took this to mean that they had already reviewed the patient's orders, were aware the patient was on a Heparin drip, but failed to notice this order (obviously they were busy), not that they were already pre-occupied with other nursing activities and the order was written without their knowledge. You are focusing on the latter situation, but as I read the OP that was not their situation. From my understanding of the OP's situation, as written, the suggestions that were given to pay close attention for med order changes, especially for high risk meds, and to review how one is prioritizing care in order to see if this activity can be given a higher priority, is applicable. If I was in the OP's situation and the situation was just as I said I understood it to be, and I told other nurses I overlooked the order, having already reviewed the orders (knowing the patient had a high risk med currently infusing), I would expect to be told some variation of: "You need to pay close/better attention for medication (especially high risk medication) order changes in future."
As far as nurses being able to know about orders that were written/changed without their knowledge while they were busy doing other things, I agree with you that it would be very helpful to have some way of notifying the nurse of this. In the absence of that, I can't think of what one can do other than striving to re-check the orders at appropriate intervals (as another poster stated, the appropriate intervals to do this would depend on unit policy and sense (to me sense means taking account of what is currently going on with the patient, how sick are they, what type of meds/treatment they are receiving, etc.).
In regard to what types of actions should be de-prioritized so that an RN will always and automatically know about orders that were written when they were busy doing other things, I think you are asking the wrong question. De-prioritizing/re-prioritizing actions by itself won't enable an RN to always and automatically have knowledge of orders that were written when they were busy doing other things.
You are the second person who has stated this obvious now, and I think we can all agree. This is basic nursing. It is insulting to suggest that this is the main reason that RNs do not provide ideal care in every circumstance.
I think part of this has to do with the way different people on this thread have interpreted the OP, and, based on their interpretation of the OP, on what they perceive the implications to be for nursing practice. I assume we are all here because we are open to learning and improving our practice.
I still haven't made the connection in how "knowing your patients" enables you to have ESP about what orders were written about highly sensitive meds while you are busy in a 1:5 or 1:6 floor assignment.
I believe I've addressed this above.
Somewhere there is a time frame within which it would be considered reasonable good practice to discover and act upon such an order. I'm curious what that time frame is. I don't have the answer. Overall, it seems that this delay strikes some people as being worse because it involves heparin. So how often should nurses look to make sure no one has quietly changed the patient's heparin orders? And what about all the other other medications that are important for other patients? How often should the RN check to see if someone quietly changed one of those orders? Or any order?
As previously mentioned, the OP said that they overlooked the order to discontinue the Heparin. I understood from this that they were saying that they had reviewed the orders but failed to notice this already existing order, and that they already knew that the patient was on a Heparin drip. So the remedy here, as I understood the OP, as I see the situation, is to make an effort to pay closer attention to checking the orders (especially for high risk meds), and to review one's prioritization to see if this activity deserves a higher care priority.
I am understanding that you believe there should be an exact time frame for re-checking/implementing orders. But how would that make sense when every patient's situation is different? Nurses are expected to use nursing judgment and to individualize the care they provide.

I have typed my thoughts in bold below your comments.

JKL33 · Aug 18, 2020

21 minutes ago, Susie2310 said:
I think part of this has to do with the way different people on this thread have interpreted the OP, and, based on their interpretation of the OP, on what they perceive the implications to be for nursing practice.

Thanks, you are right I didn't porifice out the meaning of overlooked in this scenario. It could be a couple of different things, such as the possibility you are responding to or something like having been in the chart briefly for some other purpose and not noticing there were new orders.

I don't know.

24 minutes ago, Susie2310 said:
I can't think of what one can do other than striving to re-check the orders at appropriate intervals (as another poster stated, the appropriate intervals to do this would depend on unit policy and sense (to me sense means taking account of what is currently going on with the patient, how sick are they, what type of meds/treatment they are receiving, etc.).

I agree completely. Believe it or not that's the point I've been trying to get at. Still, I don't particularly like it...because of how easily minutes turn into hours when things are busy. I believe many of us have very good intentions and things just take a long time. Something simple and not-life-or-death (but still very necessary and still part of the job) like toileting someone could take 20 minutes. If a patient isn't doing well....20, 30, 40+ minutes. Or more.

Something simple about the old door flags, I guess ?. You could run up and down the halls doing any number of things and see that you had orders all the way down at the other end of the hall. In the version of EMR I'm using right now, we don't see any orders unless we're in the chart with the orders--and new orders don't particularly draw attention, either. I certainly hope those things are not the case for nurses on the floors! (And in my case, it doesn't really help that all orders are STAT and thus they are immediately posted as being in "overtime" [aka late]--the instant they populate.) So everything is already "late" all the time. I guess I just get tired of it, you know? We also have a tracker boards that indicate there are orders on a chart. But if one of them is PRN order the icon never goes away, so it doesn't work to keep glancing for new order icons.

41 minutes ago, Susie2310 said:
I am understanding that you believe there should be an exact time frame for re-checking/implementing orders. But how would that make sense when every patient's situation is different? Nurses are expected to use nursing judgment and to individualize the care they provide.

Nah, I don't really think that; I'd have to ponder it more. I do agree with ^ you and was more asking the people who seemed very upset about this scenario to answer the question as a means of furthering the discussion. Because you're right, it doesn't make sense. It always has to do with the patient's situation (generally speaking, when trying to prioritize numerous routine tasks and orders).

That's the reason for the way I answered the question when it was posed back to me earlier in the thread: How long would I want someone to take to discontinue my elderly loved one's heparin gtt? My answer is....it depends. If it isn't STAT and it isn't NOW and there is nothing to suggest that it is individually particularly urgent...then: as soon as they reasonably can.