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A 70-year-old woman, an insulin-controlled diabetic patient, was receiving 80 mg of prednisone daily. This dosage had been administered for two weeks. The patient's doctor wanted to begin withdrawal of the steroid and wrote an order to "decrease prednisone 5 mg daily."
A unit clerk transcribed the order and the new dose listed was 5mg daily-not 75 mg daily. This was checked by a nurse who evidently interpreted the order in the same way. The following day the patient received only 5 mg (her insulin dosage remained the same).
Later that day, the patient collapsed and the hospital resuscitation team was called. Administration of glucose assisted in reviving her. Blood glucose at the time of collapse was less than 50 mg per ml.
The situation could have been prevented by a more clearly phrased doctor's order. What should have been written was "Decrease prednisone by 5 mg daily," or better yet, "Decrease prednisone to 75 mg daily." Nursing personnel must also be aware of the need for gradual withdrawal from corticosteroids when patients receive such high doses for more than a week. '