Need some advice

Would it have made a difference if the patient had died? Corrective actions should always focus on the behavior - not the outcome. Although it is tempting, we have to avoid 'grading' incidents based upon the result because that is often the result of luck or chance. The only thing we can change is behavior. Sometimes we need a wake-up call to help us see that taking shortcuts or skipping steps actually does have an impact on patient safety & outcomes. I am sure that the nurse in question will be much more vigilant in medication administration from now on.

Human beings make mistakes and unfortunately, our patients are usually just one human error away from a catastrophe. As health care professionals, we have to step back and realize that we are actually just links in the very complicated process of delivering patient care. We need to build in as many fail-safes as we can (chart checks, co-signing, etc.) but the most important fail-safe is our own diligence. When we catch an error/mistake, that information has a direct impact - either by correcting the problem behavior or improving the system.

You're right! At our facility nurses write each other up for things that are not even worth it (such as not restocking the medication cart with syringes and alcohol pads...the supply room is 2 feet from the nurses station) that I forgot the main reason why we have incident/occurrence reports. Thank you for reminding me.

Did the doctor write an order to hold these meds prior to the procedure?

Is there a written protocol to follow for this and other tests/procedures?

If not.. it is the doctor and the unit manager that need to be written up!

Did the doctor write an order to hold these meds prior to the procedure?

Is there a written protocol to follow for this and other tests/procedures?

If not.. it is the doctor and the unit manager that need to be written up!

I agree, however the nurse is still the last person to touch those meds. As Esme stated, it is pretty standard to hold anticoags prior to a surgical procedure. I know on my floor, patients will get a Lovenox in the AM (0800-0900) but the evening dose will be held. By the evening, the physician should discontinue the Lovenox, but they don't always do that. The nurse should have called the physician to clarify.

OP, you did a great job! :hug:

I don't believe there was an order to hold the Plavix but on our floor it is protocol to hold lovenox and aspirin before a surgical procedure unless told otherwise. It wasn't just the nurses fault. It was a number of people.

Let's look at the bigger picture. I am sure that the chart went with her. The OR should have questioned the medications that were given.

And yourself. Did you check? As you said it was a number of people. And it's an "incident report" not a snitch sheet. And I don't think you should feel bad at all about filling it out.

Where I'm working, it seems that there's always opportunities for incident reporting...Needlestick Injuries,falls, patient absconding..etc.etc. I guess it helped in investigations and improving healthcare system. Take heart though, filling in the Incident reporting sometimes does save someone from law suits..

Doesn't "She bled out" mean she ...bled out..as in no more blood left in the body??

was this pacemaker really put in the patient in the OR? i would think that it highly unlikely. i would think holding plavix for a procedure and not an 'operation' is NOT standard. i would hedge a bet it was the lovenox that did it. would you give a heparin injection before your patient was going to have an invasive procedure? (no).

but someone with bad cad/vasc disease i would think holding plavix would have been a discussion made loooonngg before the day of the procedure. the nurses and/or docs (most likely it would fall on the nurses as we all know)...shoulda looked at what meds were given prior to the procedure too.....

its not clear did the patient get the lovenox AFTER the pacemaker placement? (i dont see a rationale for giving it either way). and is this an 'experienced' nurse that has or has not done this before? :redlight: