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!!
Specializes in Community Health, Med-Surg, Home Health.
I don't work in LTC or med-surg, but to me, it would be a good idea to place the date of the previous and upcoming date for the next INR in the MAR, and if there is a flow sheet for PT/INR, it should be right next to the MAR as a double reminder to the nurse to check before she administers. I don't believe it should be done in a million different places, but if that is the rule of thumb for that facility, then, they should all be in convienent places for the nurse to do them at one time for checks and balances.
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!!
never give coumadin without knowing the inr. if the inr order is not on the mar, that should be a clue that you need to do some digging.
where i work, coumadin is usually given at noon. i don't get to work until three. however, i always check the chart for pharmacy's handwritten note indicating the inr and what dose to give, then check against the lab report and the mar to see that the inr was correctly transcribed and that the correct dose was given. even though i did not give the coumadin, i make a point of knowing the inr. it's an important safety check that every shift is responsible for. i even write the inr and the coumadin dose on my brain sheet, so that i can quickly access this information if questioned about it.
if your facility does not do this already, maybe it would help if every resident on anticoagulation therapy had a green, yellow, orange, red, or some bright colored sticker with "anticoagulation therapy" in big bold letters placed on their mar, just to remind each nurse to double check the inr. it seems to me that relying on one nurse (the night shift) to do this important safety check is the problem, and that there should be a process in place where each shift is responsible for this very important safety check.
I agree with NancyNurse. Relying on one person to do something thats very important is a problem. The reason the OP and her co-workers were written up was the fact that they gave the med. The night nurse didn't. Yeah she should have transcribed the order but didn't so it was up to the OP and her co-workers to make sure the correct order was transribed because after all, they are giving the med.
Today I had a similar problem. My patients have their labs drawn at midnight. In SICU we have electrolyte protocols to determine how to supplement low K/Mg. According to the night RN she supplemented the low K/Mg but it was never documented that she did. So i had to redraw labs and go from there. You just can't rely on one person to do something.
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:
-this is a great way to monitor the coumadin, i will take this to my supervisor and don and see how they'll take it from there! i dont know why my facility doesnt have special measures in places for high alert drugs like coumadin! this has been a great learning lesson! thanks!
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.
thankyou for all the responses, at first when the supervisor explained that we would all be written up, i tried to argue that the problem started with the night nurse! but i'm the one giving the med! yes i am overworked but this is my license, sure it'll make my medpass a little longer but hey i like nursing! errors are very easy to make so i hope my supervisor follows through with a plan to prevent something like this! lesson learned, thank goodness the patient wasn't harmed!
This situation needs to be approached from a systems level ... do not blame individuals at all, no negative "write ups" or blaming whichever poor nurse someone doesn't like and is one cog in a long process of error, but look at the entire system to improve it to minimize occurrence of such errors. This is the most proactive, positive way to approach these issues IMHO. The goal should not be blaming people for stuff, but to change the system so that these errors concerning any medication, especially one like coumadin, are much less likely to occur again. However, I am a realist and do not believe there are very many LTC facilities (or other health care facilities, for that matter) with quality management who would even think of doing such a thing. Many facilities are stuck in blame the nurse mode of managing problems.
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
:omy:
The highest INR I have ever seen was in the 8 range, and it was a person who had come into the hospital from outside.
Those people had not been monitored for a LONG time.
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.
By definition, write-ups are intimidating--esp. to newer nurses--and having been an RN for 21 years--EVERY write-up is punitive and held against you on your yearly eval....we had one DON who would document his conversations (ie--non-write-up teaching moments) with you in a notebook, no official paperwork unless there was a negative patient outcome or it was a repeat conversation--at the end of the year, they went away....much more supportive nurturing method--writing up EVERY med error is more about convering management butt than teaching or taking care of your nurses--back to the delusion that writing someone elese up protects you--all it does is cost you loyalty and respect--ruling with fear as your tool encourages the people under you to continue the trend of eating your young---there has to be a better way....
At my hospital, the pharmacist often is the one that doses the coumadin based on the day's PT/INR score. I was taught to NEVER give that dose of coumadin, no matter what it said in the MAR, without checking the written order in the patient's orders first (even if pharmacy isn't adjusting the dose daily). You just check it...I know you don't work in acute care, but even before we give lovenox/heparin or arixtra we always check written orders first no matter what the MAR says.
pagandeva2000, LPN
7,984 Posts
I don't work in LTC or med-surg, but to me, it would be a good idea to place the date of the previous and upcoming date for the next INR in the MAR, and if there is a flow sheet for PT/INR, it should be right next to the MAR as a double reminder to the nurse to check before she administers. I don't believe it should be done in a million different places, but if that is the rule of thumb for that facility, then, they should all be in convienent places for the nurse to do them at one time for checks and balances.