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A nurse on a medical unit went to check on an elderly man who'd been treated for a small stasis ulcer and was scheduled for discharge the next day. When she assessed him, she found him unresponsive to painful stimuli, pale, diaphoretic, and with a weak, thready pulse. Immediately, she called the doctor.
At first, the doctor thought the patient had developed a pulmonary embolism. Then the nurse remembered, "He got his first dose of Tolinase (tolazamide) this morning."
Because the patient wasn't diabetic, the doctor denied ordering tolazamide, an oral hypoglycemic agent. But the nurse showed him his handwritten order on the patient's chart. Then the doctor realized what had happened: He'd meant to write the order for a different patient, but had mixed up the two patients' charts.
The doctor diagnosed the elderly patient as having developed hypoglycemia from the tolazamide and ordered intravenous glucose. The patient's condition rapidly returned to normal.
This potentially life-threatening error could have been prevented if the doctor had been more careful when writing his orders, and by double-checking the patient's name and room number on the front of the chart and the order sheet.
But equally important, the nurse who administered the tolazamide should have questioned why a hypoglycemic agent was ordered for a patient who didn't have diabetes. If she'd asked the doctor before administering the drug, she would have prevented the error.
So know your patient's diagnosis and the indication for the drug you're about to give. If the two don't agree, check with the doctor to make sure the order's correct.