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!!
Whatever. A write-up by any other name is still a write-up.
Writing a person up is different than writing the incident up. From my viewpoint 6 people were wrote up, it seems to me that it isnt so much the person as the process here.
I think it shows that the OP has a poor manager, one who teaches with fear and either unable/unwilling to examine the problem and come up with a real solution.
every single nurse who administered the coumadin (and didn't doublecheck for the last pt/inr) should have been written up.
we are talking about the risk of a fatal error, here.
and there are too many nurses who mutter to themselves, "it's not my job to check...".
well, darn it, it IS everyone's job when it comes to life or death.
these write ups will ensure that all involved will administer critical meds more discriminately.
it's not about being punitive.
it's about trying to keep a pt alive.
leslie
But it wasnt about knowing what the PT/INR was. It was about having the phrase "check pt/inr on 05/01." I agree you should always know what the pt/inr is, I could even see documenting that along with the date on the MAR. But the order just seems to me as unnecessary documentation.
A nurse writes that phrase on the doctor's orders usually as a verbal or telephone order, writes out a lab copy then writes it on the MAR. Is it really necessary to write that 3 times?
We have paper MARS... the typical 31 days. So if I just received an order and the PT/INR is to be checked in one week... I go to the date on the MAR and write INR right where someone will have to initial that they gave the drug. I do this, so whoever is giving coumadin stops and makes sure that a PT/INR has been done and to make sure they received new orders.
The person who gives the coumadin will have to literally initial over INR.
I don't monkey with coumadin. I almost had a lady bleed out on me. It was scary. When I am doing my med pass, it comes to a screeching halt when I come across coumadin.
Also our pharmacy wants to know when the next PT/INR is and they will print it on the med label.
Specializes in LTC,Hospice/palliative care,acute care.
Where I work "getting written up","writing someone up" "writing an incident report" and "counseling" all kind of mean the same thing. I don't see the purpose for debating that as is happening in the thread-It's all a learning experience.
The point is-when the state department of health sees an error like this they also want to see a corrective action.I am betting that everyone involved was included in the "write up" or whatever you want to call it.Everyone involved was probably counseled.We recently had a spate of similar problems. Something I was involved in could have ended in a very bad outcome-the night shift nurse responsible for auditing charts had to go to the classroom for additional training (if anyone would like to see the actual department of health inspection report e-mail me-I'll send you the addie)
Our facility has a coumadin flow sheet-every nurse on each shift should know when the labs are obtained and be following through to make sure they were.We also include all new orders on the shift report-evenings should routinely eyeball them to make sure they were transcribed correctly prior to night shift's audit.LTC residents are supposed to be "stable" (HA ha) so we do not audit every chart on every shift. Also-our labs come through the fax machine IN THE SUPERVISORS OFFICE. Your supervisor should have been checking up on this .
BOTH nurses following you dropped the ball but you made the error intitially so you are all at fault.
So-plan of correction.Check your policy and procedure to see what info should be included on the 24 hour report.New orders should be-that will alert everyone to be vigilant.
Suggest a flow sheet for your PT/INR. Ours includes present dose and last lab results (people were actually calling docs for orders without that info at hand)
Make sure you have some notage posted prominently in the nurses station to alert all staff to your routine ,including prn staff.Everyone should be aware of when those labs are drawn and be on the look out for any new orders.
When you receive a new order-place the MAR right next to that chart-do NOT note the actual order until you have actually transcribed it completely. To cover yourself and protect your residents have your supervisor or the oncoming shift go over any new orders in report.
In LTC you want to be VERY aware of your residents on blood thinners,insulins and anti seizure meds.More mistakes happen with thoses drugs then any other in my LTC....
A nurse writes that phrase on the doctor's orders usually as a verbal or telephone order, writes out a lab copy then writes it on the MAR. Is it really necessary to write that 3 times?
noryn, even if it takes writing it in 20 different places, we have to ensure that all are on the same page...
and that actually, it is NOT the noc nurse's job, but everyone's.
noryn, even if it takes writing it in 20 different places, we have to ensure that all are on the same page...
and that actually, it is NOT the noc nurse's job, but everyone's.
leslie
But writing something in 20 different places is not feasible in long term care and adds to the workload further causing errors. I would also argue that it further complicates or creates confusion.
Here is my issue--that phrase on the MAR means very little. The most important place for that order is the lab book. What good does it do on the MAR? They draw PT/INRs one day a week, so the nurses already know the day. Just because it is on the MAR doesnt mean it will be done as lab does not access the MARs.
If it was Tuesday why not come up with a policy or an order that would state something to the effect of "On Tuesdays hold coumadin until pt/inr comes back and doctor notified of results"
Again though when 6 people are being wrote up, I think there is usually a problem with the process, not lazy, stupid or uncaring employees.
We have a calendar that has all our labs to be ordered. So if I just received an order to do a PT/INR in one week... I flip forward 7 days and write it down. "Mrs. Smith - PT/INR". ALL labs go in this calendar. The unit clerk orders all labs the day prior and highlights them in yellow to let the nurses know that she did this. Therefore if someone adds a lab it is the nurses responsibility to order once the unit clerk is gone for the day.
Once I write it in the calendar... I go to the MAR and write it in the date also. You can never have to many checks and balances!
Here is my issue--that phrase on the MAR means very little. The most important place for that order is the lab book. What good does it do on the MAR? They draw PT/INRs one day a week, so the nurses already know the day. Just because it is on the MAR doesnt mean it will be done as lab does not access the MARs.
If it was Tuesday why not come up with a policy or an order that would state something to the effect of "On Tuesdays hold coumadin until pt/inr comes back and doctor notified of results"
Again though when 6 people are being wrote up, I think there is usually a problem with the process, not lazy, stupid or uncaring employees.
So what am I missing here?
as soon as new pt/inr orders are received, a lab slip should be made out and entered into the lab book.
this new order should also be transcribed to the mar, w/that date being blocked off.
instead of orders being written like, "coumadin 3 mg po daily", it should read, "coumadin 3 mg po x 6 days, then recheck pt/intr".
it's not only making the lab aware, but every single nurse should be able to go to an mar and see the pt is on coumadin, and needs to be watched.
pt/inr's are not always routine.
if a pt has guaiac + stools, the doc is going to order a level.
if emesis is guaiac +, another level.
if cbc's are all low, another level...
too much at stake here that can depart from the norm.
and yes, there are nurses who will not go the extra step if they know someone else is supposed to be auditing...
as soon as new pt/inr orders are received, a lab slip should be made out and entered into the lab book.
this new order should also be transcribed to the mar, w/that date being blocked off.
instead of orders being written like, "coumadin 3 mg po daily", it should read, "coumadin 3 mg po x 6 days, then recheck pt/intr".
it's not only making the lab aware, but every single nurse should be able to go to an mar and see the pt is on coumadin, and needs to be watched.
pt/inr's are not always routine.
if a pt has guaiac + stools, the doc is going to order a level.
if emesis is guaiac +, another level.
if cbc's are all low, another level...
too much at stake here that can depart from the norm.
and yes, there are nurses who will not go the extra step if they know someone else is supposed to be auditing...
leslie
That is part of my point but the OP stated that they are only putting the date it is due on the MAR, nothing else. No clarification to hold, discontinue, notify the MD, etc.
SuesquatchRN, BSN, RN
10,263 Posts
Whatever. A write-up by any other name is still a write-up.