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A laboratory technician called to report a low serum potassium level of 2.4 mEq/liter for Mrs. Johnson, a newly admitted diabetic patient. (Normal range is 3.8 to 5.5 mEq/liter.) The unit secretary who took the call notified the charge nurse and, when the computer printout of the result was run, placed it on Mrs. Johnson's chart.
The nurse checked the lab value against the printout and called the patient's doctor. Although he was surprised by the report, he ordered an I.V. infusion of potassium chloride, 60 liter, to be given over 8 hours during the night. He also ordere ' another serum potassium test done in the morning.
The next morning, Mrs. Johnson's potassium level was 6.6 mEq/liter. As the nurse was calling the doctor to repor abnormally high level, she glanced at the previous day's prin and saw that the patient name wasn't Johnson but Jackson. The unit secretary had apparently heard the name wrong on the phone and hadn't checked it on the printout.
Mrs. Johnson needed several 3D-gram doses of oral Kayexalate over the next 2 days to bring her serum potassium level back to normal. And Mrs. Jackson required immediate potassium supplementation.
Such potentially dangerous errors needn't happen. Verify abnormal lab values before taking steps to treat them. Just as important: Read the patient's name on every computer printout and compare it with the name on the chart.