rn.5245

I am on a DOU step-down unit at a small community hospital. We only do our own draws if the patient has a PICC, central line, or port, all peripheral draws are done by phlebotomy. Basically I should have followed up, and although this is no excuse, it was very chaotic on our floor that day because we were in the middle of day 1 of transitioning to a new electronic charting system, a very atypical day, and so lab and pharmacy were chaotic as well up on the floors...meds being entered wrong, orders incorrect, and not fully knowing how to correct things yet...During the whole transition process, and every other day I have had as a nurse, that first transition day was uniquely the most confusing and stressful day... I definitely dropped the ball with this detail, and so did other departments...I always ask someone or get help when I am unsure...and under normal circumstances I would have had a calm second to think it through...

Thank you all for sharing your knowledge and experience with me. I am in my first year of nursing, about 9 months in... I definitely see where I fell short in this scenario, being the last line of defense I know I should have followed up. I'm not sure if this changes anything, but upon review all my papers and the mar, I realized that the vanco was actually scheduled for 1700, with the trough at 1600. When lab never came, the day nurse passed it to me by calling pharm and changing the time to midnight. But this was not really clear, as I did not realize the full situation.... So I am frustrated with myself in that I mishandled the situation, and just bummed that I did not realize/clarify with each team member that was involved, because I was on the receiving end of each of their actions, while they got to pass it down the line... I hope this doesn't turn into a write up, although I would understand if it does happen...i will think of it every time i have a trough in the future, as i add it to my collection of mishaps i will hopefully never repeat this mistake!

Thanks for the feedback. I definitely see what you are saying. At my facility I have often seen hold parameters written for vanco and the lab draw, but other times not. When I see orders such as "draw vanco trough at...hold next dose if >20 (or what level they specify), this very clearly means wait and use the result to determine whether to give. When they said "draw trough at...pharmacy to dose" instead of "draw trough at...hold dose if..." I saw this as one has parameters, one doesnt, and in the second case the trough is to see how things are at the current vanco dose/frequency. But then again, if a BP med had no parameters and the BP is low, this is not implying give the med no matter what their BP is. You would clarify before giving. You are definitely right that just because pharm sends something, this is not a green light that it is ok to give, but I just thought that in the case of "pharmacy to dose", they were deciding how much and when to give... So I guess I was just wondering if ordering a vanco trough was usually meant to determine the next dose, or if it is sometimes meant to change future doses, but not necessarily change the admin time. Thanks for replying to my post.

Hi! I am trying to figure out if I took the right action with an order for vanco and trough levels. My patient was on vanco q 24 hours. The doctor wrote the following order: "vanco iv pharmacy to dose." "draw vanco trough at 1600." When i arrived for my 7pm shift, the trough for 1600 had still not been drawn, as the lab was backed up. The daily vanco was scheduled for midnight. The renal labs were wnl. I checked the trough from 2 days prior, and it was low, 4.6, so i called pharmacy about the order and they sent me the scheduled dose, which i gave at midnight. Then at 1:30 am lab calls with a vanco level of 27. Apparently they drew it late, on my shift. This patient had past orders for vanco troughs and specific hold/wait parameters for the dose, and as i understood it, since this order didnt instruct to wait for the trough and didnt give parameters to hold vanco if the trough is a certain level, I was supposed to give it based on pharmacy and the schedule for the dose, and the trough was not to determine my midnight dose. My question is, did make an error bc i didnt wait for the trough, or did i follow the order correctly as written? Any feedback would be so helpful. Thanks!