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On a busy surgical unit, a doctor stated to a nurse that his patient "needed a B12'" Then he asked to see the patient's old chart. The nurse retrieved the chart from a file and started to ask the doctor about his order but was called to the phone.
When the nurse finished the phone call and returned, she found the doctor had gone without leaving any written orders. She was unsure whether he wanted the patient to be given a vitamin B12 injection or have blood drawn to determine his B12 level. She paged the doctor but got no answer. She decided that since the doctor hadn't mentioned a dose, he must have wanted a B12 level, so she wrote the order for it.
A few days later, the doctor stopped by to tell the nurse his patient had "gotten a B12 level" instead of a vitamin B12 injection. Because of the misunderstanding, the patient had undergone an unnecessary blood test and hadn't received medication he needed.
This error occurred because a rushed doctor didn't take time to write an order, and a busy nurse neglected to clarify his verbal order. Don't make the same mistake. No matter how busy you are, always clarify an ambiguous order before carrying it out. You'll be saving yourself time in the end ... and you may be saving your patient from a serious medication error.