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A nurse took a telephone order from a doctor to irrigate a patient's bladder with sterile Neosporin G. U. Irrigant, an antibiotic solution manufactured by Burroughs Wellcome. When referring to the irrigant, however, the doctor incorrectly called it Burroughs' solution.
The nurse assumed the doctor meant Burow's solution, a topical astringent. So she wrote on the patient's chart: Irrigate bladder b.i.d., via catheter, with Burow's solution. The patient received several irrigations with Burow's solution.
The doctor found the error when he countersigned the order. Fortunately, the patient suffered no ill effects from irrigation with the nonsterile astringent. .. but he didn't receive the antibiotic's intended benefits, either.
From this experience, the nurse, doctor, and pharmacist learned firsthand about the danger of telephone orders-what's heard isn't always what's being requested. To prevent this confusion, always question the doctor when you're not familiar with a drug's name. Then, when checking with the pharmacist, tell him exactly why the drug's being prescribed.
Finally, work toward establishing a policy that doctors countersign telephone orders within 24 hours ... and that those orders be limited to emergencies.