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A patient with an eating disorder had just been admitted to the psychiatric unit. Before the nurse could assess her, an internist gave her a physical examination. He wrote this order:
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Both the nurse and the pharmacist interpreted the order as "eat Ex-Lax, one P.O. b.i.d." That didn't make sense, especially for a patient with an eating disorder. Before giving the Ex-Lax, the nurse consulted the attending psychiatrist. He was also puzzled by the order, so he discontinued it.
Neither the nurse nor the psychiatrist knew that during her physical the patient had complained of cold symptoms. The internist had actually ordered "Entex LA, one P.O. b.i.d." His sloppy handwriting had been misinterpreted. Unfortunately, the patient missed several doses of the decongestant-expectorant.
A more serious error-giving a laxative to a patient with an eating disorder-was avoided because the nurse knew her patient's diagnosis and the action of Ex-Lax. The internist could have helped by including more information with the original order. Many doctors aren't aware that indicating a drug's dosage form and its purpose can help nurses and pharmacists differentiate between drug names that look alike when handwritten. For example, a more complete order for Entex LA should have included "one tablet b.i.d. p.r.n. for cold symptoms." No one should have confused that for Ex-Lax.