Has your common sense ever gone out the widow at some point leaving you wondering when the stupid stick hit you afterwards?
During the graveyard shifts, the staff nurses/lpn along with the charge nurse are in charge of doing 24 hr checks on their pts. This ususally involves going through all the pt charts, ensuring all the orders for the day are done and all the labs for the next day are ordered. All the orders for each pt are written in their invidual kardex's. Each Kardex is basically a handy guide utilized by all the charge nurses to keep track of all pt information and their individual orders including things like IV fluids. Usually, the charge nurse will go through each chart on the ward and order any labs for the next day and write down orders into the kardex. The staff rn/lpn in charge of the pt will also do a reconcilliation for their pts-writing down all pt orders and ordering anything the charge nurse misses.
Anyway, I was reconcilling one of my pt's charts. This pt had been admitted during the swing shift. I noticed that in addition to the IV NSS order there was an order that said "IV Heprin per protocol". In my mind all I could think of was "hm, heprin's really important. they couldn't possibly have missed this. The heprin was probably d/c'd at the clinic" So instead of informing the charge nurse, I assumed the order was d/c'd.
In the AM, as I was getting ready to leave. The charge nurse suddenly leaves the report room and says, "---- , there was a heparin order! Did you notice it in your 24hr check?" At first I was confused. I told her, that I had assumed it was d/c'd. Long story short, it wasn't. The nurse in the swing shift had not endorsed to us that the pt was supposed to be on a heprin drip. In fact, the pt drip had never been started! The charge nurse said that she herself had not looked at that chart and therefore did not know about the drip until she was doing report.
Thankfull nothing was wrong with the pt and his cardiac labs had been decreasing since he was admitted and he had been fine. Anyway, after ensuring pt safety and ordering stat pt/inrs and heparin iv, my charge nurse wrote up the incident report. In the report she mentions my name- to what effect I'm not sure-but I think it might have been as a witness.
I know your probably all looking at me like I'm an idiot. Don't worry, I feel like I am. I have NO idea what I was thinking at the time! I've been getting better and reconciling my charts. I'm usually pretty good at catching things that get missed but that night-holy crap I have no idea where my common sense went too. I was really hit hard by the stupid stick I guess. In fact, if anything is d/c'd it would say "d/c so and so" if it had been the heparin it would have specifically said "d/c heparin." I swear I just wasn't thinking about this at the time.
My question is, I know I share the some of the blame for not realizing what I was reading, but who's fault would this actually be? Mine soley? My charge nurse for not reviewing the chart herself? or the charge nurse from the previous shift?
