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A medical/surgical nurse who had floated to the emergency department admitted an 18-month-old boy suffering from an acute asthma attack. A doctor called out an order for atropine, 0.25 mg, to be given intramuscularly. The nurse repeated the order to the doctor, then rushed to prepare the dose. When she passed the doctor in the hallway, she repeated the order. He again confirmed it.
After she administered the drug, the nurse charted the order and showed it to the doctor. He told her she'd just given the child an overdose. What he'd meant to say was 0.025 mg (not 0.25) of atropine. Fortunately, the child experienced only intense flushing.
The doctor apologized for yelling out the incorrect order, but that was little consolation for the nurse, who realized she'd made a potentially serious error.
She and her colleagues learned a valuable lesson that's become a hospital policy: A doctor can't give-and a nurse can't accept-a verbal order when the doctor is on the unit. He has to write it on the patient's chart. The only exceptions are code emergencies or when the doctor is actively performing a procedure.
And the nurse learned that she should always look up and confirm doses-or at least double-check them with another knowledgeable professional-when she's unfamiliar with a drug