Error Number 18. Not listening to your patient if he questions his medication or the dosage

A student nurse drew up 85 units of NPH insulin for a diabetic patient, as ordered on the patient's medication Kardex. But when she and her instructor approached the patient to administer the insulin, he protested that there was too much in the syringe. When the student explained that an order had been written for 85 units, the patient refused the injection, saying his usual dose was 10 units each morning.

Immediately, the student and instructor checked the patient's medication Kardex and the doctor's original order. Both specified 85 units. Then they called the patient's doctor-who told them the patient was correct. The doctor immediately changed the order to 10 units of NPH insulin every morning.

Hoping to get to the root of the error, the nursing instructor checked with the doctor who'd been on call the night before, when the patient was admitted. This doctor explained that he'd taken the order for 85 units from the patient's chart for his last admission-a year before. Apparently, he never asked the patient whether his insulin requirements had changed since the last admission. Nor did he check with the patient's regular doctor.

By listening to the patient, these nurses prevented a dangerous medication error. Too often, a patient's questions about his medication are not taken seriously. Yet patients are becoming more aware of the need to know what they're taking. And their knowledge has become increasingly important in preventing medication errors.

So listen to your patient. If he says the dose looks too large or his usual pills are a different color, hold the dose and confirm the order with his doctor.

And take every opportunity to encourage a patient to be a careful health consumer. Teach him his drugs' names, what they're used for, what they look like, and his usual dosage of each. When you administer a drug, say something like "Here's your daily dose of NPH insulin for your diabetes-10 units." That way, the patient will become familiar with his drugs and will be more likely to question a different tablet or a changed dose.