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A diabetic patient underwent surgery and was sent to the recovery room with an order for a stat blood glucose. The recovery room nurse drew the blood sample and sent it to the laboratory.
Later, when she called the laboratory for the test result, the technician said "442." The nurse repeated "442?" The technician said yes, and hung up. The nurse then called the surgeon and gave him the same number. He, in turn, ordered insulin for the patient.
Just before she added the insulin to the patient's I.V., the nurse got a call from the same technician. "Something's been bothering me about your phone call," he said. "Did I tell you the test result was 442?" The nurse said yes. "Well," said the technician, "I meant for you to call extension 442 to get the result."
The nurse called the extension, found that the patient's blood glucose level was 90 mg/I00 ml (within normal limits), and had the insulin order canceled.
In a similar incident, a nurse requested a stat blood glucose test for Mr. Jones, the patient in Room 315. When the technician called back with the result, he said, "I have the blood glucose result on Mr. Jones, 315." The busy nurse wrote down 315, said thanks, and abruptly hung up.
She then told the patient's doctor the blood glucose level was 315. The doctor ordered insulin, and in this case, the nurse administered it. When she received the written laboratory report later, she discovered her error: Mr. Jones's blood glucose level was actually 650 mg/100 ml. She called the doctor, who ordered an additional dose of insulin.
Luckily, neither of these patients suffered any harm. But the nurses and technicians learned the value of clarifying test results taken or given by telephone.
You can avoid a similar mistake by repeating back the information you've just been given; for example, "You say that Mr. Jones's blood glucose level is 315 mg/l00 ml?" That extra precaution won't take extra time, but it will prevent misinterpreting those crucial laboratory test results