What Can Be Done to Avoid this error?

  1. I will try to make this short and cut right to the chase:
    Nurse in a long-term care facility. Normally work the day shift. Very fast pace, working short-staffed is the norm, but that goes without saying in LTC. I'm juggling admissions, getting breakfast and lunch insulins/CGBs done, passing meds, residents falling ass-over-teakettle, handling the phones, call docs and waiting for call-backs, advocating for families, and trying to do the charting/assessments for 38 people...you all know the LTC drill. At the end of the day, it's typical for 3pm to come and no docs have called me back, which is sometimes no big deal, but 9 days ago, around 2:45, a doc calls me back to give new orders for coumadin based on INRs that I had faxed over earlier in the day. The way it works at my place of employment is this: we have a little 3 ring binder where we put the INRs of the day that are awaiting callbacks from docs. Once we get the new orders, we write them in the binder, put the order into the computer (we use and eMar) and obviously schedule the lab for the next draw. Guess what I didn't do? I missed entering the new Coumadin order AND never scheduled a lab draw for one of my residents. It was written in the binder, but I must have spaced out or gotten pulled in another direction. No real good excuse at all.

    So, here we are, 9 days later, and the pharmacy sends us an alert stating we haven't ordered a new dose of Coumadin for this resident. That is when my co-worker and I discover my BIG mistake. So this resident hadn't gotten Coumadin for 9 days. Naturally a med error, DON and family contacted. Bed bound resident with Afib, assessment showed no glaring issues, MD was contacted and ordered for INR to be drawn in the morning and resume the last dose resident was on (4mg).

    What I'm trying to figure out is how I can avoid this from occurring again. In reading up on other's posts here regarding med errors/order errors, it seems as though my facility would benefit from some kind of system where orders are checked by another person...particularly Coumadin and other high alert meds. I take full responsibility for flubbing this one, and I'm certainly going to make sure I drop the multi-tasking mentality when handling INRs and other essential labs, but what are other's thoughts on checking orders in LTC, and how is it done in your facilities?
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    About callienewh

    Joined: Oct '16; Posts: 1


  3. by   hppygr8ful
    At the LTC where I worked the noc shift was responsible for a chart audit. You have to have layers of redundancy where orders are concerned.

  4. by   caffeinatednurse
    At our facility, the RN supervisor handles scheduling the INR rechecks & determining the new Coumadin dosage (via telephone order w/Dr). The supervisors aren't at the bedside & therefore have more time to do these things & it eliminates errors like these from happening. They typically also put the order in but if they don't, they'll remind the nurse that the order needs to be put in.

    Our night shift nurses also audit the new orders every night. They report discrepancies found & are responsible for putting in missed orders. The supervisors go behind them & check their work. So there's at least 3 sets of eyes on each new order.
  5. by   heron
    Is there a way to program the emr to flag overdue Coumadin orders before they are automatically dc?
  6. by   morte
    if the previous order had been put in correctly the need for labs would have come up and the nurse that would have given the next dose should have come looking for the OP. in my last job, i had wing nurses chasing me for the new orders! they wanted NO part of a med error!
  7. by   poppycat
    Since you're using an eMAR, is there a way to have an alert pop up for scheduling the next INR at the time the new dose order is entered?
  8. by   NotAllWhoWandeRN
    This will not improve systemic issues, but if you make any daily paper brain or task list, include ordering updated Coumadin and INRs. Don't leave until you've done that and marked it off.

    I'm glad the patient came to no harm, and I applaud you for owning your mistake and using it to look for ways to better your practice. It's people like you that make great nurses.
  9. by   Cruella de ville
    Would your facility consider a generic Coumarin order?
    Something that says "this patient is in Coumarin, if no orders for dosing please review"?
    Basically something to get the nurse passing meds to look for a new order if they don't see a dose of Coumarin for that night?
    This could run every night in addition to the specific Coumarin order.
  10. by   cecile9155
    At my facility it is the night nurse's responsibility to verify orders. We have a similar system of writing telephone orders in a binder. Our problem is that the day nurses don't always write down the phone orders. Then the order goes unverified.
  11. by   CoffeeRTC
    We still use paper charting in our facility.

    We have a separate order in the MAR that says Check PT/ INR before administering coumadin. It is timed for the 3-11 shift.
    The 11-7 nurse redlines all of the charts nightly too. This would have caught the error if you had wrote an order for it but didn't take it off.
    We also have a binder where we schedule the labs. When the lab comes back we are supposed to check it off and not if the MD was called and we got new orders.

    Since this is LTC, most nurses get to know the resident. Why didn't anyone realize they weren't getting coumadin? It's easy to see on the paper MAR. All the old orders are there and marked off.
  12. by   canoehead
    The first day was your error, but the next eight days; that was a system error. Other nurses looking at the MAR should have seen that she was on Coumadin, but there wasn't an order for that day. The pharmacist should have picked it up. There should be a double checking system on night shift for just this type of issue.
  13. by   joyjan
    So the previous LTC place I worked in, they have a Coumadin sheet that tells the recent dose, the date it was ordered and the next INR date. The MAR was in grid form and we basically put a line on days before and after the date range of when the Coumadin should be given and write INR on the date it is ordered to be drawn. That way, you have a constant reminder of your coumadins and INR draw dates.