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A patient suffering an acute asthma attack was admitted to a busy emergency department (ED). The ED doctor prescribed, among other things, 0.5 mg of the bronchodilator terbutaline (Brethine, Bricanyl).
Because the ED order sheet had so much written on it, the doctor had to squeeze in his order for terbutaline. He wrote it like this:
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Although the decimal point was hard to see, the ED nurses were familiar with the drug and administered the correct dose.
The patient's condition improved in the ED, but the doctor decided to admit him to the hospital for observation. Another doctor, called in to write the admitting orders, simply copied the orders from the ED order sheet. Not noticing the decimal point in front of the 5 in the terbutaline order, he wrote 5 mg as the dose.
The patient and his admission orders were transferred to a medical floor. There, the nurse transcribing the orders asked the admitting doctor if he really meant to give the patient 5 mg of terbutaline. The doctor replied, "I wrote the order, didn't I?" So the nurse drew up 5 mg of terbutaline and administered it to the patient.
Within 10 minutes, the patient developed hypertension, tachycardia, and a pounding headache from this injection-which was 10 times what he should have received. He had to be moved to the intensive care unit, where he spent 2 days recovering from the overdose.
Several factors led to this medication error. Most important, the ED doctor should have written a zero before the decimal point in his order. In the cramped space on the order sheet, the decimal point virtually disappeared.
Second, the admitting doctor shouldn't have copied the orders without fully understanding them. And when the transcribing nurse questioned his order for 5 mg, he should have listened to her concerns.
Third, the transcribing nurse shouldn't have let the doctor's abrupt attitude deter her from checking the correct dosage range for terbutaline herself, either with another colleague or in a drug
reference. Obviously, she knew something was wrong with the order, so she shouldn't have carried it out until she was satisfied it was correct.
Abbreviating an order to fit it onto a crowded order sheet may seem like a good idea. But in this incident, the squeezed-in order seriously harmed a patient. So starting now, make it a habit to always write a zero before a decimal point on medication order transcriptions. You'll definitely save confusion about the dose, and you may just save a patient's life