ERROR!!! Pharmacy Vs Nursing

[Sparda29]

2 CCU patients are both on heparin drips. Heparin drips are currently on backorder, thus pharmacy has to compound the drips.

7pm - nurse A calls down requesting heparin drip for CCU #1
7pm - nurse B calls down requesting heparin drip for CCU #6

Note: both drips are of same concentration (25000 units/250 mL)

Pharmacy tech runs up the drip for CCU #6 and hands it to nurse A (and according to the nurse, says it is for CCU #1, however the label clearly states it is for CCU#6.) @715pm

CCU#1's heparin is taken upstairs with the normal hospital messenger @745pm

At 930PM, the nurse for CCU#6 calls and says she needs a heparin drip. We say we made it and sent it up, she swears she can't find it. I go upstairs to search for it. It's not in the medication room, it's not in CCU#6's room. On a hunch, I check CCU#1's room and I find it hanging on CCU#1's IV pole and being administered.

Meanwhile, CCU#1's heparin drip was sitting in the medication room.

Nursing claims that the error is on the pharmacy because the technician handed a medication over to the nurse and told her it was for CCU#1 even though the label has CCU#6's info on it.

Pharmacy claims the error is on nursing for not checking the label (doesn't matter what was told to the nurse, she still has to check the label). The pharmacy tech claims that he just handed it to her and said it was for CCU.

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[Jibby321]

Sounds like a mess.

 

[BeLikeBueller]

Sounds like you guys need to implement bedside barcode scanning and transition more from a blame culture model to a just culture model

 

[BenJammin]

That mentality by the nurses doesn't fly in the world of law or business so why is it applicable in health care?

 

[BeLikeBueller]

That mentality by the nurses doesn't fly in the world of law or business so why is it applicable in health care?

# nurses >>>> # pharmacists

political power of nurses in the hospital >>>> that of pharmacy

 

[gwarm01]

Sounds like you guys need to implement bedside barcode scanning and transition more from a blame culture model to a just culture model

Absolutely this. I'm surprised your hospital doesn't have this, Sparda. Just from reading this forum casually I've picked up that you are working in a fairly prominent hospital in NYC, right? It is a great safety measure to implement, especially since your nurses can get a bit overworked sometimes and not be as careful about the medication as we are.

 

[Sparda29]

Absolutely this. I'm surprised your hospital doesn't have this, Sparda. Just from reading this forum casually I've picked up that you are working in a fairly prominent hospital in NYC, right? It is a great safety measure to implement, especially since your nurses can get a bit overworked sometimes and not be as careful about the medication as we are.

Right now I'm at a small community hospital in a prominent health system, this hospital needs a lot of improvements. I'm transferring to the systems peds medical center.

 

[BeLikeBueller]

Right now I'm at a small community hospital in a prominent health system, this hospital needs a lot of improvements. I'm transferring to the systems peds medical center.

Regardless, the nursing vs pharmacy thing going on here is not beneficial to patient safety. Hence the need to implement a just culture. The nurses should be coached that they have a key roll in preventing med errors, since they are the last check in the hospital to make sure that the right patient is receiving the right drug at the right dose at the right time, etc., etc.

 

[KARM12]

Both sides did something that contributed to the error. Pharm tech should have asked the RN the name or room number of the drip he had. RN should have checked before hanging the bag.

 

[pharmasaur]

i dont see why they would not double check the name esp. if its something like frickin HEPARIN. zantac tablet...ok....so the pt got the wrong rate too??? or was the rate ok?

 

[KidPharmD]

The nursing vs pharmacy issue is helped a lot by moving to a "Just Culture" model. However, I see a couple of things here. First, if there isn't a verification process when the tech hands the medication off (most places don't do this), then the tech can hardly be faulted. Would it have been better to double check they were handing it to the right nurse? Absolutely, but you can't fault them if they haven't been trained to verify this. Second, the nurse violated the 5 rights (Right patient, medication, route, dose, and time) and this is definitely something that all nurses are taught to verify every time they give medication. Barcoding helps, but so does 2 patient identifiers. If the label on the bag was applied properly then a simple double check would have prevented this. Our institution requires 2 nurses to double check the 5 rights before giving a high risk medication like heparin.

Medication errors are best prevented by saying "what could my group have done differently" instead of "who is to blame."

 

[KidPharmD]

BTW: "Just Culture" is something that has to be created by the hospital/system. So, I imagine that if you are transferring within the same system then it won't be any better where you are going.

 

[Dred Pirate]

Sounds like you guys need to implement bedside barcode scanning and transition more from a blame culture model to a just culture model

instead of blaming - work on how to prevent this.

First - I hope the rate was incorrect was it? (as far as the rate running on the patient) - that should be from the Emar not the bag on a titratable drip.

2. Most of the error is the nurse, but instead of focusing blame, focus on what went wrong, how to prevent it, etc. And yes, bedside barcoding would likely have averted this error

 

[Sparda29]

i dont see why they would not double check the name esp. if its something like frickin HEPARIN. zantac tablet...ok....so the pt got the wrong rate too??? or was the rate ok?

I don't know about the rate. The rate is usually on the pharmacy label, but it also shows up on the eMAR. So if they looked at the eMAR they'd have the correct rate.

 

[Sparda29]

BTW: "Just Culture" is something that has to be created by the hospital/system. So, I imagine that if you are transferring within the same system then it won't be any better where you are going.

I know it will be better. I'm going from a small community hospital that is union where everyone seems like they just don't give a **** to the pediatric medical center.

On my interview I could tell straight away that there was a difference in culture. While they do play around, work is serious over there and they are much more careful because it's a pediatric population.

The hospital where I'm transferring out of used to be an independent community hospital that was close to being closed when the health-system bought them out. From what I've been hearing, they are going to close down the medical floors, expand the emergency department and expand the surgical suites. The orthopedic surgery program here is the one thing that this hospital does really well.

 

[farmadiazepine]

Off topic, but Sparda do you work in an NYC hospital in Mahattan?

 

[Dred Pirate]

I don't know about the rate. The rate is usually on the pharmacy label, but it also shows up on the eMAR. So if they looked at the eMAR they'd have the correct rate.

well heparin is often titrated every 4-12 hours (depending on policy, stability of anti X-a levels, etc), so they should always look in the Emar, our pharamcy labels state this, the level is titrated more often than the bagneeds to be replaced

 

[Sparda29]

Off topic, but Sparda do you work in an NYC hospital in Mahattan?

Nope. Nassau.

 

[sosoo]

i agree before the nurse administers any medication they should check the label. hospital policies?

 

[ethyl]

It's an administration error. Pharmacy does not administer the medication. Your manager/director has probably accepted a portion of the blame already to make the issue go away.

 

[extra07extra]

why is matter?? both iv drips is same concentration.. this both is get same thing

 

[pharm B]

why is matter?? both iv drips is same concentration.. this both is get same thing

 

[Sparda29]

why is matter?? both iv drips is same concentration.. this both is get same thing

That's not the point. The point is the ****ing nurses are borrowing drugs from other patients carts (not supposed to). This is how meds disappear and nurses end up calling the pharmacy again to send the drug up again.

What if it wasn't the same concentration? What if I had compounded a double concentration for the other patient? She wouldn't have known since she didn't read the ****ing label.

 

[extra07extra]

What is you mean? you is say before both is same concentration so if same drug and same concentration, both patients is get same thing, no matter becauase both patient good and no problem...what is deal??

 

[sakigt]

So in retail, if patient x picks up patient y's prescription its ok as long as the medication and directions are the same?

 

[Sparda29]

What is you mean? you is say before both is same concentration so if same drug and same concentration, both patients is get same thing, no matter becauase both patient good and no problem...what is deal??

Because the ****ing label doesn't have their name on it.

 

[extra07extra]

So in retail, if patient x picks up patient y's prescription its ok as long as the medication and directions are the same?

I am not see no harm if both patient is taking is same drug and same dierection

 

[Sparda29]

I am not see no harm if both patient is taking is same drug and same dierection

The label also has the infusion rate on it which is different from patient to patient. The nurse could potentially program the wrong the infusion rate if the hospital doesn't have EMAR.

 

[KidPharmD]

I am not see no harm if both patient is taking is same drug and same dierection

These are doses prepared for specific patients. The fact that the patients happened to be on the same dose is dumb luck. Besides, these two patients were being taken care of by two different nurses, so one nurse wouldn't have known that they were on the same dose.

Just because there is no harm, doesn't mean it isn't an error (and a serious one at that).

If you can't understand that, it worries me that you are a pharmacist somewhere.

 

[nguyenulm]

I am not see no harm if both patient is taking is same drug and same dierection

Quit trolling you fob.

 

[extra07extra]

These are doses prepared for specific patients. The fact that the patients happened to be on the same dose is dumb luck. Besides, these two patients were being taken care of by two different nurses, so one nurse wouldn't have known that they were on the same dose.

Just because there is no harm, doesn't mean it isn't an error (and a serious one at that).

If you can't understand that, it worries me that you are a pharmacist somewhere.

It is no matter is that same drug both patient is on use same dose and so patient is get same drug so they is ok. It is no problem is as long patient is for care for. Yes is maybe error but just wrong name but is ok becauase both patient is ok good

 

[spacecowgirl]

1) Get rid of the finger pointing blame culture
2) You need to have a policy for independent double checks on high risk meds. We have PINCH meds (PCAs/epiduals, Insulin drips, Neo/peds, Cheno, Heparin drips) all require, by the EMR, a double check to document.
3) you need bedside barcoding

 

[KidPharmD]

It is no matter is that same drug both patient is on use same dose and so patient is get same drug so they is ok. It is no problem is as long patient is for care for. Yes is maybe error but just wrong name but is ok becauase both patient is ok good

The only reason there wasn't harm was PURE DUMB LUCK. I'm sorry, but I am not okay with relying on luck to prevent KILLING a patient. There was a failure of the system here and it almost harmed a patient. The fact that it didn't does not excuse the error. BTW, it would have been a HIPPA violation if a family member saw the bag.

 

[pharm B]

It is no matter is that same drug both patient is on use same dose and so patient is get same drug so they is ok. It is no problem is as long patient is for care for. Yes is maybe error but just wrong name but is ok becauase both patient is ok good

You've gotta be trolling.

 

[extra07extra]

The only reason there wasn't harm was PURE DUMB LUCK. I'm sorry, but I am not okay with relying on luck to prevent KILLING a patient. There was a failure of the system here and it almost harmed a patient. The fact that it didn't does not excuse the error. BTW, it would have been a HIPPA violation if a family member saw the bag.

I am agree and is say yes is error but also yes patient is receieve treatment so is ok beacauase patient is get same drug and is same dose anyway so is good. it is no bother if patient no get harm so is ok. it is nobody see hipaa is serious anyway.

 

[Sparda29]

The only reason there wasn't harm was PURE DUMB LUCK. I'm sorry, but I am not okay with relying on luck to prevent KILLING a patient. There was a failure of the system here and it almost harmed a patient. The fact that it didn't does not excuse the error. BTW, it would have been a HIPPA violation if a family member saw the bag.

A family member was in the room when I caught the error. I'm surprised they didn't figure out there was an error done when I chewed out the nurse.

I am agree and is say yes is error but also yes patient is receieve treatment so is ok beacauase patient is get same drug and is same dose anyway so is good. it is no bother if patient no get harm so is ok. it is nobody see hipaa is serious anyway.

It would have been better if the patient just went an hour or two without the heparin.

1) Get rid of the finger pointing blame culture
2) You need to have a policy for independent double checks on high risk meds. We have PINCH meds (PCAs/epiduals, Insulin drips, Neo/peds, Cheno, Heparin drips) all require, by the EMR, a double check to document.
3) you need bedside barcoding

Nurses always love to blame pharmacy, so when we get something on them, I have to put it on blast. Bedside barcoding coming in a few months.

 

[DrBowtie]

A family member was in the room when I caught the error. I'm surprised they didn't figure out there was an error done when I chewed out the nurse.

You chewed out a nurse in the patients room, in front of family? What a circus.....

 

[extra07extra]

A family member was in the room when I caught the error. I'm surprised they didn't figure out there was an error done when I chewed out the nurse.

I am not understand what you is chew on...i am think you is not in chew on nurse as you say?

 

[Sparda29]

It's unprofessional to chew them out in front of the family.

How would it have been better if the patient didn't get heparin?

You chewed out a nurse in the patients room, in front of family? What a circus.....

Nah, not inside the patient's room but in the CCU. This nurse was the reason why the other nurse could not find the heparin for her patient and why we had to make another heparin and run it upstairs afterwards.

I am not understand what you is chew on...i am think you is not in chew on nurse as you say?

LOL. No one tell him.

 

[MackandBlues]

I once had a nurse hang the wrong TPN on a patient. Same thing, they were blaming pharmacy for not bringing it up and lo and behold its running on another patient in the same unit.

 

[Cauris]

I am not understand what you is chew on...i am think you is not in chew on nurse as you say?

i really hope that you're trolling.

 

[extra07extra]

Nah, not inside the patient's room but in the CCU. This nurse was the reason why the other nurse could not find the heparin for her patient and why we had to make another heparin and run it upstairs afterwards.

LOL. No one tell him.

Why is you say no one tell him?? I is only not understand what is you mean. I am is try to understand so why no one tell me?? How is you like if is you ask qeuestion becauase you no understand and is no one tell you?? I am just is try to learn

 

[spacecowgirl]

Nurses always love to blame pharmacy, so when we get something on them, I have to put it on blast.

Does that really make you feel better at the end of the day? One of the reasons I love my job now is the great interaction among departments. Where I interned there was just a ton of animonsity and blame and everyone seemed miserable all of the time. Not to mention it sure doesn't improve patient care. Try to be the bigger, more professional person.

 

[Sparda29]

Does that really make you feel better at the end of the day? One of the reasons I love my job now is the great interaction among departments. Where I interned there was just a ton of animonsity and blame and everyone seemed miserable all of the time. Not to mention it sure doesn't improve patient care. Try to be the bigger, more professional person.

Well at my new job, I won't be able to do that. I'm going to the pediatric hospital so hopefully there's no BS there. Won't care if they lose the med, I'll just make one and find out what happened to it later.

One of the things I'm hoping for at the new gig: hopefully nurses who are much prettier, younger and nicer. At my current hospital, all of the nurses are old and fugly. None of them are even remotely close to my age (26).

 

[Jibby321]

^^^^^^^^^^lol

So they are fugly and they make mistakes? What's up with that?

 

[MackandBlues]

Well at my new job, I won't be able to do that. I'm going to the pediatric hospital so hopefully there's no BS there. Won't care if they lose the med, I'll just make one and find out what happened to it later.

One of the things I'm hoping for at the new gig: hopefully nurses who are much prettier, younger and nicer. At my current hospital, all of the nurses are old and fugly. None of them are even remotely close to my age (26).

younger, prettier and nicer doesn't mean that they won't make mistakes. In fact could mean the opposite, they are brand new and have no clue what they are doing! yesterday I went up to the floor to help solve a problem and asked a young nurse who had mr. x. She was like "mr. x? mr. x? who is that?" then I looked, she had mr.x's chart pulled up on her computer. Sigh. Don't even know which patients she has...

 

[SDN]

Why is you say no one tell him?? I is only not understand what is you mean. I am is try to understand so why no one tell me?? How is you like if is you ask qeuestion becauase you no understand and is no one tell you?? I am just is try to learn

You should avoid trolling from your workplace in California and stop posting with multiple accounts. We do report repeated violations to schools or employers for network abuse.