Stopped a heparin drip too early, feeling awful

[tired_panda]

After a crazy and frazzling night during a week that ended up being very emotionally trying for me outside of work, I had a patient who developed a really severe sinus headache, began dry heaving from the pain, and was refusing all medication as she told me that the only thing that helped with her pain was the steam from a shower. She was also on a heparin drip that was supposed to be stopped in preparation for a surgery later that day. I had falsely transcribed that the drip was supposed to be stopped at 5am, and in the craziness of the situation, I looked at my watch, saw it was 5am, and helped my patient with the shower, disconnecting her from heparin. I only realized my mistake during change of shift- learning that the drip was supposed to be stopped at 8. I did everything I could to reach the doctor, and the oncoming nurse found me tearfully waiting on the phone. She told me everything would be okay, and that she would take the call back from the doctor. She told me to go home, she would figure out the situation, and I could write up an incident report when I am back tonight. I just feel awful, especially since I was never able to reach the doctor. I know I should have double checked the time, but I felt so certain and so much was happening at once. I'm new, I understand the importance of heparin, but I am not sure of the weight of the error. Has anyone done something similar, or is anyone able to tell me how bad this is? I feel so incredibly terrible over it

[FL_Nurse92]

Why was the patient on heparin?

[tired_panda]

She had afib and was taking a po anticoagulant at home

[NotReady4PrimeTime, RN]

Heparin's anticoagulant effect lasts about 4 hours after it's stopped. If you restarted it as soon as you discovered your error, it should be fine. This is definitely NOT something to beat yourself up over.

[Apples&Oranges]

If she was having an invasive procedure later that day, the drip probably should have been stopped prior to 8am anyway. Not trying to minimize missing the details of an order, but you absolutely did NOT cause harm to this patient. All things considered, you learned MUCH more from this minor mistake, and in the long run, saved future patients so much harm from this experience (by way of the caution that you will now have with high risk drips) than if you had simply read the order correctly.

Overall, your patients will be safer with you tomorrow than they were yesterday. That is a great, great thing.

Take a deep breath, understand that you made a mistake, and appreciate that you learned a great lesson. We have ALL made mistakes. Take it seriously, and move on. You are fine. The patient is fine. Double check next time. All is well.

[se56]

I COMPLETELY agree with the other posters. This is a minor error in the grand scheme of things. Heparin has a substantial half life and if she was also taking an oral anticoagulant in addition then she was protected. Like the others said, learn from this little error! I've seen nurses make more serious errors and everything has turned out OK.

There is an interesting discussion regarding making errors in nursing and the emotional toll it takes on the RN. The errors we make weigh so heavily on our minds and hearts and can have serious emotional consequences for a nurse, especially a novice RN. Try not to worry so much, learn and grow from the error and you'll be a better nurse in the long run for it. You already know you are a good nurse because you care so much! Remember that!

[Apples&Oranges]

Update to my previous response: I had the opposite experience happen just this week. Patient was schedule to go to the OR at 9am that day. When I got report, as primary RN and charge, I learned that the patient was STILL on a high dose heparin gtt. WHAT? The night nurse said that she had contacted the overnight surgery cover to find out when the gtt should be stopped and was told "I don't know, I'm just covering. Don't change anything."

You can guess how my conversation with the surgery PA at 07:05 went... The entire OR schedule had to be rearranged, the surgeon was PISSED OFF that the night nurse had not had enough sense to stop the drip at 5am. I was blessed with the experience of explaining to the irate surgical team (the whole gaggle arrived in force to berate my whole staff) that their covering resident had directed the night nurse to keep the drip. The response was, "Did anyone working last night actually go to nursing school?"

While that was inappropriate, (and addressed) the message was understandable. I apologized. Again. We all make mistakes.