Written Up Again?? what's wrong with this picture??

Published

Specializes in Licensed Practical Nurse.

so i got written up again for the same problem but in a different way!! here's the info, i've been working in ltc for 9 months as a new nurse! 7 months ago i was written up for not transcribing a coumadin order from the m.d order book to the mar!! i missed the order! now i, along with about 5 other nurses are being written up for a coumadin order! here is the issue, the night nurse are supposed to audit new orders, at my facility pt/inr is done weekly for patients on coumadin the date that the pt/inr should be done is supposed to be indicated on the mar! well the night nurse didnt transcribe the pt/inr order on the mar, so the evening nurses continued to give the coumadin! so we all got written up! as a new nurse i've learned from this, but i do believe something should be in place to monitor coumadin specifically! the supervisor said we really need to be careful! and should have picked up on this, she said we should go through the entire order book for new orders! that is a good idea, but between dressing, documentation, med pass... when??, if the night nurse had been more careful, none of us would've gotten in trouble! i just feel so unprotected, there are no measures to catch mistakes like these at my facility besides the night nurse which in this case failed!! my question is how does your facility handle med errors such as these?? and what's wrong with this picture?? i know i definetely learned a lesson!!

Up Vote Up Vote ×
Specializes in Case mgmt., rehab, (CRRN), LTC & psych.

Coumadin (warfarin) is a med that you never want to play around with. I've seen death, disability, and unnecessary hospitalizations arise because nurses continued to give (or not give) Coumadin without being vigilant regarding labs and orders. I've listed a few true cases below that have occurred at my former workplace.

1. A patient on anticoagulant therapy died because the evening nurses continued to give the same dose of Coumadin for 6 weeks straight without any labwork to monitor the protimes. This woman bled to death; her PT was over 100 and the INR was 6.5

2. A patient "went downhill" and had to be sent to the ER. The hospital determined he had multiple pulmonary emboli, and wanted to know what dosage of Coumadin he had been receiving. Oops! He hadn't received any Coumadin in nearly 1 month, because the order was missed by a sloppy evening nurse.

Up Vote Up Vote ×
Specializes in subacute/ltc.

I personally prefer the MAR sheet that is only for coumad in. The left side where the order goes has the date of the last PT/INR and the results, also when the next PT/INR is due. We alway write PT/INR in on the date the lab is due. The nurse then knows to check the lab, make Dr aware of results and write the orders.

I hear you feeling you and your coworkers where unjustly treated, However if you are giving coumadin and you see no changes on there MARS each week you have a personal responsibility to see when the PT/INR was ordered, and if there is a current lab to see if it .was reconciled...and if not call the doc.

I speak from experience....I once "caught" a PT/INR result that was incorrectly transcribed...the nurse wrote 1.62. PT/INR carried to the third place???? Checked the lab the INR was 16.2

Can you say 20 meq of vit K in house and a trip to the ER....and a very

ugly outcome.

I work per diem and was about to give 5 mg of Coumadin when I noticed there were no new orders for two weeks...looked for a lab none ordered. Called doc got an order for in house INR it was 15.8

Better outcome this time.

Yes, it can be overwhelming......however it needs to be done.

Tres

Up Vote Up Vote ×
Specializes in ICU/Critical Care.

While I understand that the night nurse was suppose to transcribe the order and didn't, you and the other nurses should have verified in that there were no new med orders. It's everyone's job to make sure that the patients are getting the correct meds, not just the night nurse's.

Up Vote Up Vote ×

Make it your rule...NEVER give coumadin unless you know the last PT/INR

you are the safety net for the patient - they depend on you - I totally understand the being overworked - believe me - but you have to have your own internal rules for your safe nursing practice and med admin......

most of the biggest lessons we learn are from 'mistakes'....unfortunately .....be glad it wasn't a worse outcome like those described by others....

welcome to nursing :nurse:

Up Vote Up Vote ×

My coumadin orders changed twice a week. There are certain drugs for which one can't just blindly trust the MAR. Coumadin, Dig, dilantin, anything that lowers heart rate or BP....

You have to be more vigilant. And I think that you will be, now.

Don't worry about the write-up. 2 in 9 months is nothing. And if she's a good DON it's for learning, not punishment.

Up Vote Up Vote ×
Make it your rule...NEVER give coumadin unless you know the last PT/INR

you are the safety net for the patient - they depend on you - I totally understand the being overworked - believe me - but you have to have your own internal rules for your safe nursing practice and med admin......

most of the biggest lessons we learn are from 'mistakes'....unfortunately .....be glad it wasn't a worse outcome like those described by others....

welcome to nursing :nurse:

Exactly! To me giving coumadin without lab levels is like giving sliding scale insulin without a glucometer reading. Thinking of it that way reminded me to always know the lab level.

Up Vote Up Vote ×
My coumadin orders changed twice a week. There are certain drugs for which one can't just blindly trust the MAR. Coumadin, Dig, dilantin, anything that lowers heart rate or BP....

You have to be more vigilant. And I think that you will be, now.

Don't worry about the write-up. 2 in 9 months is nothing. And if she's a good DON it's for learning, not punishment.

Talking, counseling, instructing, telling her how to do what needs to be done (since she is still pretty new) - these are for learning. A write-up is punitive. It is scary and it is demeaning. It is angry and unnecessary.

Up Vote Up Vote ×
Talking, counseling, instructing, telling her how to do what needs to be done (since she is still pretty new) - these are for learning. A write-up is punitive. It is scary and it is demeaning. It is angry and unnecessary.

No necessarily. My last LTC job wrote up all med errors, period, to track trends, teach if necessary, and cover their butts from lawsuits and state.

I don't think, from what she has said her DON said, that she was trying to demean or scare her. It sounds like she's trying to protect her residents.

Up Vote Up Vote ×
Specializes in Hospice, ALF, Prison.

Thanks for your posting, and the subsequent comments.

What is the expected 'best practice' length of time beween PT/INR tests that one should expect?

Thanks!

Up Vote Up Vote ×
No necessarily. My last LTC job wrote up all med errors, period, to track trends, teach if necessary, and cover their butts from lawsuits and state.

I don't think, from what she has said her DON said, that she was trying to demean or scare her. It sounds like she's trying to protect her residents.

I disagree, an incident report would serve the same purpose. Write ups are intimidating and do hurt morale.

Up Vote Up Vote ×
Specializes in LTC, Med-Surg.

I'm an LPN at a LTC facility. In the medex Warfarin is on a separate page just as Accuchecks and insulins are on their own page separate from the rest of the medications. The next INR draw date is on the warfarin page with the med order. On PM shift, wing nurses do NOT give warfarin until our charge nurse double-checks each and every warfarin order against the resident's last PT/INR results. The charge has a binder specifically for residents on warfarin with copies of their orders and lab results. After verifying the orders, the charge will come down the halls with the lists of residents who get warfarin, how many mg, whether it's held, etc. Then we can give the med. This is usually the first thing the charge does after getting report when coming on shift. Maybe something like this would be helpful.:wink2:

Up Vote Up Vote ×
+ Join the Discussion