med error - heparin drip

Nurses Medications

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A little background; I'm a day shift float pool nurse with two years experience. When we're high census, we open a surge unit, typically 12 patients with two RN's and one CNA. Surge is the float pools home, so we typically run with all float staff. I've been in my current position for 11 months.

So it's 18:15, night shift will be here in 15 minutes. I had an admission at 17:30, so once I got him settled in went to give a couple of 18:00 meds I had left. Walked into patients room who had bilateral PE's and was getting heparin at 1,100 units an hour. Found her IV pump to be on hold. Tried to resume the drip to find that she had phlebitis and therefore would not run. Started a new IV and resumed drip, but needed a new bag. At this point the oncoming nurse was with me so we ordered a new bag (why heparin is not stocked in our Pyxis, I do not know) and went to double check and hang the new bag.

The patients aPTT had just come back as 40.1. I verified the lab result with oncoming RN and then pulled up specifications in the eMAR. Our policy is if aPTT is under 34 to bolus, based on weight. I misread and was flustered with all that was going on (including patients calling out for bathroom while I was trying to get supplies.) It actually read if WEIGHT is under 45 kg to bolus 3000 units, but in that moment I was thinking aPTT. Based on specifications below we also increased rate by 100 units an hour. So, we set a 3000 unit bolus and changed the rate, signed the paper and went on with report.

It wasn't until I was halfway home that I realized she did not need the bolus, just an increase. I called the nurse and told her of the mistake. She is in the new grad program. She wasn't mad, more just afraid she may end up in trouble and unsure of what to do next. I suggested she page the hospitalist for further instructions, whether to get a stat aPTT, etc. I told her I would put in an incident report for myself and call our boss. I called my boss and left him a voicemail explaining there was a med error regarding heparin drip, I would put in incident report, left my phone number.

I called a couple hours later and she said that the hospitalist said to move the rate back to 1,100 an hour and to leave the next aPTT alone (it would be drawn at midnight.)

I'm really worried of what repercussions I may have coming. My only other med error was probably nine months ago, and that was forgetting to unclamp the secondary tubing for a q8h antibiotic. Days off without pay? Termination? Report to board of nursing? Has anyone experienced a similar situation and have any words of support? My boss is very reasonable and fair, but I recognize the severity of the error, as it's a high alert drug. Thanks in advance for responses.

Specializes in SICU, trauma, neuro.

Hugs! Mistakes happen, you reported it and measures were taken to offset any harm to the pt. Most places recognize that the approach should be non-punitive -- I mean, most of us would never self-report med errors if it would put our livelihood at risk. (Not sure if you read the "got fired for a med error" thread, but *if* that story is true, it wasn't your typical med errorS. It was sheer negligence.)

For what it's worth, I have read through the discipline records on my state's BON site. NONE of the license losses or suspensions were for med errors. They were for pt abuse (physical, sexual, financial); non-work related felony convictions (financial exploitation of family, statutory rape); failing to comply with stipulations r/t drug diversion/impaired practice; one was theft of controlled substances from home care pt's home; and one theft of a DEA number and Rx pad.

Mistakes happen; Beating yourself up won't make you a better nurse, learning from it will. You took appropriate follow up measures, and I doubt you'd get fired for one error. If errors happen continuously and frequently then maybe, but it sounds like you learned something and that's what matters.

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