Medication Error In Hospital!

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M

Mb

Hello everyone:

Here goes......this is my second update regarding my husband's tricuspid valve repair last Wednesday.

This morning, the Dr. decided to give him a "bolus" of coumaden, since his INR was still at 1.4 after two/three days of dosing at 10mg. (He usually takes 7.5). So they gave him 15 mg. - That is fine. Then they gave it to him a SECOND time. He questioned them....said he thought they had already dosed him with the coumaden, and the nurse checked, and said no, he hadn't gotten in. An hour later the PA came in, and told us he had in fact been given a total of 30mg. of coumaden.

Add that to the still high heart rate.....he will not be coming home tomorrow.

He is at a first class hospital, with a first class cardiologist and a first class surgeon. Who would have imagined.......

Marybeth
 
Sorry to hear it. My experience personal and otherwise with "first class facilities" proper after care is a HUGE issue. Keep your eyes open.:eek:

Take care.
 
So sorry to read this Marybeth. Another example of why we are our own best advocates. Hope this doesn't have bad consequences and that he gets home soon. Hang in there, Marybeth!
 
I haven't been on the computer for a couple of hours, and was hoping to hear some good news about Wayne, and now this--unbelievable!! So that is major mistake number two!

I can feel your anxiety--I know how it feels. If I were you, I'd ask that the nurse who made the error in not even recording his first dose, be removed from the case and not ever take care of Wayne again, and be thoroughly reprimanded. You have that right. To heck with what they think of you.

You need to speak with the head nurse, and his surgeon.

Bring a big notebook, and start writing things down right in front of them.

Bad care is everywhere. You just never know when or how it's going to affect you or your loved ones.

The only way to get rid of bad caregivers is to make a stink about it.
 
My husband's hospital (he's a nurse) has a "3 strikes and you're out" policy when it comes to med mistakes. I don't know that all facillities have this same policy, but I know it wouldn't be taken lightly.
 
that is unforgiveable. Something of the sort happened when my bro was in local hosp and I wrote the owner, who said he investigated, wrote me back that they were not responsible to get the med my brother was rxed. they were negligent. Any court would have approved brother's case but it just wasn't something we wanted to do. I hope that all will be well for Wayne.
 
Marybeth,

When I first read your post I thought, "Oh my lord, this just couldn't happen!" My second immediate thought was "Oh, yes it can." What a shame. There are supposed to be so many safeguards, but I guess when they tell you to be sure to have your own advocate, they're not kidding. Hope there are no serious side effects and that things progress smoothly from here on out.

Jan
 
rachel_howell said:
I'm sorry for what happened. But I'm not so sure the "bolus" strategy was valid in the first place. Two or three days isn't that long to wait for INR to reach therapeutic range, especially for a "virgin" ACT patient. Giving a one-time bolus of coumadin doesn't necessarily get it there any faster. The coumadin only inhibits new clot-producing enzymes from being formed. You still have to wait for the enzymes that are already in the system to break down. You might want to post on the Anticoagulation forum and verify that I am right about this, or maybe someone else will chime in on this issue on this thread. There are people on vr.com who are a lot more expert in coumadin management than I am. Again, I'm sorry you had this distressing event.
Click to expand...
No need Rachel, your 100% correct!

It's sad, but it happens everywhere and all the time. One more reason that I tell people and their families to keep someone with the patient at all times. I don't care how much they complain about you being there, BE THERE! You cannot afford not to anymore.
 
Most certainly don't let them give him Vit K!!!! If it's way to high, tell them to use fresh frozen plasma to bring it down. If they start him on K to counteract their screw up, they are setting him up for a huge see saw event and he'll never get out.
 
Was it the doctor who ordered the 30mg, or was it a nurse who just didn't record the first dose?

They were always giving Joe "loading" doses of Coumadin when he was off it for one reason or another, and all it did was mess up the INR for several days, creating a huge "overshoot" and then several days of "correction". God spare us all from such stupidity!
 
Nancy said:
Was it the doctor who ordered the 30mg, or was it a nurse who just didn't record the first dose?

They were always giving Joe "loading" doses of Coumadin when he was off it for one reason or another, and all it did was mess up the INR for several days, creating a huge "overshoot" and then several days of "correction". God spare us all from such stupidity!
Click to expand...

And the worst part of all---They NEVER LEARN FROM IT!
 
The other worst thing was that their "overshoot", and then period of adjustment happened AFTER he got out of the hospital, leaving me to drive all over creation to get INRs done daily until it finally got straightened out. It was horrible, especially when he wasn't feeling well.

And people wonder why the medical care costs continue to mount. Each of those times, about 30 ProTimes could have been eliminated, if someone knew what the heck they were doing.

I've even heard some doctors say, "well, let's try this", and you knew full well that we were on a fishing expedition with my poor husband caught on the hook.

Marybeth, I hope things are working out.
 
hi marybeth,
i could feel a knot developing in my stomach as i read your post. i'm so sorry this is happening.
ross and nancy are right. this is such a delicate matter to rectify.
wayne's so fortunate to have you to advocate for him, especially in these difficult areas. please let us know how things go.
wishing you all the best. you'll be in our thoughts and prayers.
be well, sylvia
 
MB.. I am so sorry that all of that has happened.
In the hospital we want to belive that the professionals have our best interest in mind always!.. I realize this stuff happens..I am just sorry that it happened to your husband.
sometimes..at least in my case..it wasn't the doctor that ordered things but rather the On Call resident.
I would investigate that a bit farther..

when I was hospitalized I had two very bad calls by residents.. that almost cost me my life.
One ordered narcotics which I am allergic too (he never looked at the red flags on my chart)
another gave me lasiks when I was in tamponade.. I was too sick to take them.. and the Actual doctor said they would have put me under. (I was severely dehydrated as well)

Again I am sorry for this set back.. hopefully you will be able to get things worked out soon, and get him home again!
 
Hello everyone:

I almost chuckled when I read Ross's comments, and others about having someone with you, to be your advocate. This is what happened.....


The surgeon thought it would be a good idea to give him 15 mg of coumaden on Tuesday morning. They came in, and told us (I WAS THERE!) THAT WAS THE PLAN. The nurse came in about an hour later, and gave Wayne medications, a number of different meds. New nurse in the afternoon, about 6 hours later. She comes in and says she has the coumaden dose. Wayne tells her he thinks he has already had it, and I agree with him. She leaves, and checks the THREE places they record medications, returns and says NO, it wasn't given to him in the morning. So she gives him the second 15 mg.
- A bit later a THIRD nurse comes in, to give him some magnesium, and he mentions this to her as he is pretty confused by the whole thing at this point. She leaves, and about a half hour later the PA who represents the doctors comes in, pretty nervous, and tells us that we were correct, and that in fact he had been given the 15mg. twice. Within the next hour, both his cardiologist and the surgeon, stop in for a visit. They are now watching him like a hawk. It appears that the first nurse who gave him the meds was covering for another nurse, and the first dosing was never recorded in any of the three proper places.

Frankly, I feel badly, that I didn't catch what was happening. The only thing I can say is that one day kind of flows into another, I am tired, he has been in the hospital since last Monday, total of ten days......The funny thing is, is that he is the one who challenged them, and he is the one on the pain meds. But even with challenging them, the nurse insisted she was right, and frankly, according to their records she was right.....the first dose was just never recorded as having been given.

And, I think Nancy is right. He will be discharged tomorrow or Friday, after which his INR will fly, and we will be chasing it for a week.

Mb

We are now keeping our own records bed side, of each medication given, how much, and by whom. So, lesson learned. If you THINK you have already been given a medication, do not rely on the hospital having kept their own records straight. And, they think their system is fail safe.

Goes to show you,
 
Unfortunately we (patients and family) are often treated as obstacles to be overcome rather than people to team up with. The time given for care has become so stretched that, should a question arise, it is often met with annoyance or arguement. During the stress of a hospital stay, patients and family can get (or are made to feel) confused and the prevailing attitude is the staff is always correct.

This is a prime example of how the staff is often not correct. They may be doing their best with the limitations given them but they often make mistakes which can be deadly indeed.

When I was in the hospital awaiting my second surgery, a nurse came in with what she said was my medication. I did not recognize any of the pills in the cup and questioned her. She got very angry and insisted I take the pills. I refused. She left in a huff. A few minutes later the head nurse came in and told me the other nurse had brought the wrong meds - DUH!!! I never saw the first nurse again (and I was there 3 weeks) so I do not know what happened. I only hope that she learned a big lesson from this as, given my situation at the time, it was possible the meds could have killed me (they were some powerful heart meds).

It is often hard to stand up to people who are there to help as we worry about offending them and getting poor treatment. However, your life can depend on questioning.

MB - glad to hear things are looking okay and they are monitoring your husband. Praying that all stays well.
 
MB, so sorry that this happened and I hope that they are able to discharge Wayne today or tomorrow and all goes well at home in your capable hands- Best wishes to you both.
 
This is exactly why they need to stop this "Loading Dose" stuff. His INR is not going to get where it needs to be any faster then if he were taking his regular dose. All it does is set him up for the old seesaw and chasing his tail. At this point, I'd just stay on my regular schedule and it'll all fall into place in due time. Sure he's going to be high for a bit, but better to be high then too low and stroke out.
 
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