mistake on heparin??

morte, LPN, LVN · Jun 25, 2011

Actually, this is usually not the nurse's call to make, rather the pharmacists, and yes you were right, but you were also wrong.
Here is why. After the 2nd PTT, the heparin dosage adjustment should be prescribed by the pharmacist. They will prescribe the changes and write for the next timed PTT draw. HOWEVER, it is the nurses responsibility to contact the pharmacist and tell them, "The PTT was such, what are you going to prescribe"?
THEY think your a PITA, but you are doing due diligence. And sometimes they forget. I have NEVER not called the pharmacist with the results of a vanco trough before hanging the next dose; because, you know what, they MIGHT not have seen it. And I really don't want to kill a pt's kidneys for such a stupid reason.

However, the PTT wasn't due on her time.....

mappers · Jun 25, 2011

Actually, this is usually not the nurse's call to make, rather the pharmacists, and yes you were right, but you were also wrong.
Here is why. After the 2nd PTT, the heparin dosage adjustment should be prescribed by the pharmacist. They will prescribe the changes and write for the next timed PTT draw. HOWEVER, it is the nurses responsibility to contact the pharmacist and tell them, "The PTT was such, what are you going to prescribe"?
THEY think your a PITA, but you are doing due diligence. And sometimes they forget. I have NEVER not called the pharmacist with the results of a vanco trough before hanging the next dose; because, you know what, they MIGHT not have seen it. And I really don't want to kill a pt's kidneys for such a stupid reason.

Not how it was done at my facility. We titrated the heparin drips per protocol. Pharmacy had nothing to do with it. Vanc was a different story.

Our protocol was worded like hers. You did a PTT in 6hours, titrated as necessary, then another PTT, etc until therapeutic. If therapeutic, next PTT in 24 hours. So you couldn't put in the next order until the last PTT results were back. So if after the first PTT was done pt was therapeutic, next one was in 24 hours.

There is very little universality in nursing.

Also, for whomever asked, in the US, there are often unit secretaries who transcribe orders from a paper chart into the computer. The nurse reviews everything to make sure it is correct and approves it "signs off" on the orders once entered.

Tait, MSN, RN · Jun 25, 2011

Actually, this is usually not the nurse's call to make, rather the pharmacists, and yes you were right, but you were also wrong.
Here is why. After the 2nd PTT, the heparin dosage adjustment should be prescribed by the pharmacist. They will prescribe the changes and write for the next timed PTT draw. HOWEVER, it is the nurses responsibility to contact the pharmacist and tell them, "The PTT was such, what are you going to prescribe"?
THEY think your a PITA, but you are doing due diligence. And sometimes they forget. I have NEVER not called the pharmacist with the results of a vanco trough before hanging the next dose; because, you know what, they MIGHT not have seen it. And I really don't want to kill a pt's kidneys for such a stupid reason.

I can't imagine trying to get my PCAs and antibiotics to the floor on time, let alone getting a pharmacist to deal with my heparin drip.

I think your facilities protocol is rare, as was mine, when I worked at a very rural hospital where heparin drips went to the 6 bed ICU along side the vents.

As far as Vanco, our pharms and MD's usually write give and not give orders for VTs.

MomRN0913 · Jun 25, 2011

If you were going according to protocol, then next nurse should have known to draw a PTT in 6 hours from the last if it was as per protocol.

NurseOnAMotorcycle, ASN, RN · Jun 25, 2011

I agree wholeheartedly. It wasn't the OP who is at fault here. It's the oncoming nurse. OP should have had them in the computer, but that's minor compared to the next nurse needing to make sure it got checked q6 hours.

(Our hospital has pre-printed sliding scales. The MD decides which strength needed. It looks a little like the insulin sliding scales.)

I_See_You_RN · Jun 25, 2011

Wow! some of the responses (the policy/practice of the hospital and not people) are ridiculous. Firstly I don't believe that it is your job to put in 24hours worth of labs slips. 1) Lab slips are suppose to closely correlate with what time the lab was drawn. What if heparin was held for an hour, or two hours, and then restarted. what if she drew the lab at n:30 instead of on the hour? What if the results come back delayed and therefore changes made were delayed? Even if you were able to enter a future time for the draw on your system the whole schedule would be thrown off. 2) Don't EVER, EVER, EVER put your name on something that you didn't do. This goes for heparin slips, Type and crosses, etc. Codes or emergencies are an exception, but even then you see what is being done and enough people are around to back you up.

Also. The nurse who didn't check the patients previous labs and did not draw the PTT's should be the one in hot water. If shift check was done she would see what time the drip was started. And then it is her responsibility to review the lab results and see 2 consecutive therapeutic draws. If not there.. then her job to continue the coag lab draws q6... thats just policy. Did she even look at the Heparin flow sheet?

And for any hospital who requires the first nurse to enter 24hour slips.. what exactly is the reasoning? It doesn't ensure that it gets done. Its repetitive if its in the orders. Its confusing and could be an issue when billing the patient. And Heparin is extremely patient specific and sometimes takes days for the patient to become therapeutic if at all, especially if you're dealing with septic/oncology patients.

I wouldn't let anyone coerce me into signing any write ups. You did your job as you should. You asked for help when needed, you did your lab draw as ordered, you documented as per policy, and you followed through and reported off to the following nurse as appropriate.

psu_213, BSN, RN · Jun 25, 2011

After the 2nd PTT, the heparin dosage adjustment should be prescribed by the pharmacist. They will prescribe the changes and write for the next timed PTT draw. HOWEVER, it is the nurses responsibility to contact the pharmacist and tell them, "The PTT was such, what are you going to prescribe"?

I certainly don't know how it works in your facility, but I have never worked in a facility that does it like this. At both places I have worked inpatient the order set calls for adjustments on the dose based on each PTT result. I.e. based on the PTT result, the nurse turns the gtt up or down as "prescribed" in the order for the gtt. Also, at both places, a 2nd nurse had to confirm the change and verify it was correctly entered on the pump. The nurse was then responsible to put in the next ptt (6 hrs if a rate change, next AM if this was at least the 2nd consecutive no change). The pharmacy had nothing to do with it (except supply the drug of course). Again, this is only based on 2 facilities, so I'm sure some do it differently...

miss81, BSN, RN · Jun 25, 2011

it does say q6h until therapeutic levels and then q24h. i believed that you were supposed to look at the ptt level and determine if it was therapeutic before putting in another lab. this is why i did not put in another one. was i wrong?

You're not wrong a my hospital! We enter the first PTT and then it is the responsibility of the nurse who is getting the results and adjusting the drip to enter the next PTT. I mean maybe the pt's PTT would have been therapeutic after the first draw (probably not, but you never know). Sounds like you followed policy to me! What if the level WAS therapeutic after the first drawn and then the pt got stuck with a needle for no reason 6 hrs later? Don't let yourself get thrown under the bus with this. Be professional but strong when you go see the DON. Explain your reasoning and that you didn't "forget" to put in the PTT, you followed the policy (if it actually says "q6h until therapeutic levels and then q24h" then how were you to to know that it wouldn't be therapeutic?)