Oh man did I miss an order

[MIA-RN1]

ok I had the same pt for 3 nights in a row. She had issues w/ blood loss, on day 2 received 2 units prbc. Crit went from 20 to 23. Afternoon crit on day 3 was 26. I call the resident. He said "Ok, thanks" and that was it. So I do my work for the shift. We were all working over-ratio d/t high census.

That specific patient was feeling great. Her color was good, her vs were stable, everything was good, she was up and walking. I took off her order for d/c in the morning and all was good.

So fastforward to today. I have the day off. I just get a call from one of the nurse supes. Apparently a doctor came over and wrote an order FOR A BLOOD TRANSFUSION at 1800 AND DID NOT TELL ANYONE. I am nuts about checking my charts and I don't know how I missed it. Said dr. apparently said that he couldn't find a nurse so didn't tell anyone about it. Ok right sure. That MIGHT be true since we all were over ratio and running around like lunatics. But I saw no red flag, no stat anything to indicate something had to be done. i DO check my charts at least once a shift and more as needed.

The patient, when informed around midnight or so by the next shift that she needed a transfusion, said that she had not seen nor spoken to a doctor at all in the evening. No one had told her about it, and she ultimately refused the transfusion.

She was fine, left in the am as planned, no harm done. That was the bottom line.

I was told "don't beat yourself up, don't lose sleep over it." Ok sure right. I told my supe that I of course accept responsibility for my part in this, and I will do whatever they need me to do, but at the same time, a blood transfusion order is a lot different than an order for tylenol or something, and the resident really should have said something to ANYONE and she totally agreed and said communication really takes two people.

Here I had this woman three nights in a row, spent lots of time with her, worried about her on my off time, trying to figure out why her crit had dropped and celebrated with her when it started going up. I thought I did really good last night with five couplets and one being a fresh-postop.

I feel terrible...

...just now supe called me back and said its the resident's fault. Reason being, I checked my charts all at the beginning of my shift and hers had the discharge order. Supe said that since I planned to d/c her, and that the resident's response to the crit was "ok thanks" AND that a crit of 26 is not so bad and we normally don't transfuse for 26, that she is bringing it up to the director as the resident's lack of communication to the nurses. She said she also called me back to tell me I am an excellent nurse and that she knew I'd be beating myself up about it and I should stop.

Ok so how do I stop? I missed something. I asked her if I was in some kind of trouble and she said no. I told her I'd do whatever I have to. But I am bothered by the fact that I let my patient down, even tho the patient doesn't know. That is what bothers me.

I feel awful.

[MIA-RN1, RN]

thank you to all who posted and pm'd me.

I walked in the LIght the Night walk tonight and I am glad that I had a few hours to not think about it.

Our system is that the md writes the orders in the chart and flags them, then the nurse takes them off and does whatever they call for. Our sectretaries don't do anything at all with any orders except the new admit orders.

What I left out of the original post was that it wasnt' even the resident I talked to that wrote the order. It was another one I'd not heard of.

I don't like the flag-chart system, I think its archaic. But its what we do there so I can't help but use it.

I like the idea of checking charts right before report, and I will implement that one. That way at least I find an order if I miss it.

Thank you all for your support. It will take a while before I feel better and a lot of it is because I really liked that patient and we had a good time when I cared for her.

Oh, and something else too...

I know I am not the first one to miss orders. I mean. the other day, I had a pt whom I received report on at 1500 and was told pt had meds ordered at midnight. Ok fine. I go to check my charts and find out that at 1400 an order was written to hold the midnight meds. Isn't that the same situation? Except that I didn't report it or make a deal of it. I just held the meds.

I don't know.

Thank you all for the support. I find so many good nurses here who understand.

[HappyNurse2005, RN]

The floor I just came from used an interesting idea so we'd know there were new orders, but it also involves the secretary.

the md would write orders, then place the chart in the rack by the secretary (where all charts with new orders go, for her to put htem in). the secretary would put them in the ocmputer, then, instead of putting them back in their normal spot, she'd put them on another rack which was on the table in the middle of hte nurses station. it was a rack that meant new orders.

so if a nurse went looking for her chart, and saw it was on the rack in the middle of the table, she knew it had new orders. hard to avoid. but that wouldn't help if hte MD didn't give the chart to the secretary, or if the secretary isn't hte one who enters orders.

[PANurseRN1]

Coopergirl: I hope you're feeling better about things today. If you lived near me, I'd take you out for a great latte and biscotti, and we'd talk about how stuff sometimes happens that is totally beyond ourr control.

Don't own this. This was not your error. If you have to look in a mirror and say it 100 times a day for the next three weeks, do it. You did nothing wrong.

[AfloydRN, BSN, RN]

We are all human, after all. Mistakes happen.

[vamedic4, EMT-P]

Do you not have a secretary who enters orders? Wouldn't she have seen it and alerted you? Or did he write an order and then stick the chart back on the shelf and leave it there?

Umm, duh - this is exactly what I was thinking!!

And she should have paged you or let you know immediately that you had new orders. I know this is hard to do at times when census is high but some orders are a BIT more important than others....

[MIA-RN1, RN]

yeah our secs only take off the initial orders whenthe pt is admitted. Everything else we have to do.

Turns out that this was a big incident and I was completely absolved. The newest batch of residents are appearing (They are rotating in 2 or 4 weeks these days) The new rule is to bring the orders to the attention of the nurse or, if the nurse can't be found, first try to find her (thats what locators are for!) and as a last resort, tell the secretary who then is responsible to tell the nurse. Its worked pretty good so far. I have found an ordersheet actually taped to the front of a chart and left off the chart rack on the counte rin the station lol but for the most part its working. THey met with all the new residents and told them exactly how to do it, so that this won't happen again.

I feel better about it and I am really neurotic about checking charts since.

[P_RN, ADN, RN]

Something I have found more than once is an order sneaked onto a previous list of orders. Using the two part order sheet, the back copy always goes to the pharmacy.

Eg: an order list with 12 items suddenly has a 13th order.....where did it come from you ask?

Getting the back copy you see that #13 was added later.

Still it's usually the Nurse who gets the onus of defending why the order was disregarded.

The flagging system is archaic. The direct entry system improves the chance that one won't be missed, but still.... There needs to be a foolproof means to achieve it.

[Jolie, BSN]

Something I have found more than once is an order sneaked onto a previous list of orders. Using the two part order sheet, the back copy always goes to the pharmacy.

Eg: an order list with 12 items suddenly has a 13th order.....where did it come from you ask?

Getting the back copy you see that #13 was added later.

Still it's usually the Nurse who gets the onus of defending why the order was disregarded.

I've worked with some physicians who did this in order to cover their butts when they realized that they'd forgotten something. My "solution" is to cross out any blank space between the final order and the physician's signature. It would also be helpful to note "12 items" in the margin when signing off the orders. We sometimes have trouble retreiving the "back copy" from pharmacy, lab, or wherever when we try to prove that the physician added something later.

[Antikigirl, ASN, RN]

I had something like this happen last week too! I had a lady who needed a blood transfusion before surgery for a hip Fx..however, the consulting MD chose to do the surgery three days later than admit day. SO we called both MD's and tried to figure out if they wanted the PRBC this day or closer to surgery. Also, she had a vit K ordered...this was also to be clarified.

Well...the MD's said to give the transfusion the PM before the AM surgery...okay great. Order was written by my charge and she just let me know to forget about all the blood stuff since it wouldn't happen my shift. So I did...

I too check my MAR's frequently..and never did see an order for the Vit K but a new order for coumadin. I gave the coumadin on schedule, and basically forgot the vit K because that was with the transfusion orders. Oops! (and the fact that why would you give coumadin and vit k???? Heck we didn't have a PT/INR done yet...it was to be done in the AM...it all was just funky!).

Well I get a call at 3am from an angry nurse asking if I had given it. I tried to explain to the best of my sleepy body what was up, and that it was't written on the MAR...she said it was..and I said "well not on my shift or I would have done it!". She called the MD and he said "not till before the infusion of PRBC's please".

So all and all I was right, the order end of the deal was crazy and didn't work well...two MD's conflicted and we had a new desk clerk that was just learning and didn't know which one was the one she should have written (and didn't ask anyone..grrr), and poor me stuck in that middle space of HUH? Well let me know then!

Needless to say I couldn't sleep that night, but I am beyond over it by now because the order was not written in my charts, the MD order was circled and being clarified my shift...and so...ehhhh...

[oneLoneNurse]

Our system is a Computer Physician Order Entry e7000 one. We have a NOW/STAT report that prints off every 4 hours to catch exactly that. Since NOW/STATs are not scheduled meds alot were being missed. On the unit I work on this has been instrumental in not missing NOWs, we have very few to none STATs.