Med error or not

This happened a few weeks ago. This facility is in a lot of trouble with the state for numerous medication errors that have been going on for months. They have medication techs that give medications on all areas.

This one day, a nurse was not told about any problems with a patient not getting coumadin or lovenox since her arrival at the facility. She did not work on that unit very often, but enough to know that there are problems there. She recieved a phone call from the doctor's office staff asking if the lovenox and coumadin had been given yesterday. There was no coumadin orders in the chart that she could find, but the lovenox had been given the previous shift and by her at 9 am. She called the PT/INR to the doctor office and asked for the coumadin and lovenox orders for that day and when the next recheck should be. She wrote the orders out on the chart. The ward clerk took off the orders and assured the nurse she had done everything to the order. The only thing the nurse had to do was note off the order. The nurse and the ward clerk both called and told the pharmacy and stressed how important it was that the patient get the medication. The nurse's shift was over and she gave report to the oncoming nurse. The coumadin and the lovenox is due on her shift. The nurse told her about the problems that they had encoutered. The charge nurse knew all about it and went in and told the rest of the story that the other nurse did not know. This conversation took place in front of the nurse coming on.

The next day the nurse that took the order and noted it off was called on the phone and fired on the sport. The medication had not been given. The ward clerk had not been honest and did not write it on the medication sheet. The med tech did not give the pill even though it was delievered in time.

Having said all that, my question to everyone is: Is that a medication error on the day shift nurse or the evening shift nurse? Should the nurse that noted off the order be fired, written up, or suspened or what?