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A diabetic nursing home patient was hospitalized to control an infection that had caused her blood glucose level to fluctuate. When she returned to the nursing home, her doctor wrote the following order for a fasting blood sugar (FBS) test:
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Following standard practice at the nursing home, a nurse drew a blood sample and sent it to the laboratory that did the home's laboratory work. She then gave the patient her breakfast and usual medications, including insulin. She noticed that since hospitalization the insulin dose was higher than usual but gave it without questioning it.
Within a few hours, the patient began to show signs of insulin shock. At about the same time, the laboratory called the nursing home to report the FBS result. It was only 57 mg/dl, so the nurse gave the patient some sugar in orange juice. She then called the doctor to tell him the test result and the patient's condition, which by this time had improved.
The doctor explained that he had wanted the insulin to be held until he'd gotten the FBS test report. He had increased the dose when the patient was hospitalized and had intended to reduce it when she was transferred back to the nursing home.
This doctor was used to practicing in a hospital, where food and medications are routinely withheld until test results are available. He was unaware that most nursing homes send laboratory work to an outside laboratory, and therefore routinely don't withhold food and medication.
Both the doctor and the nursing home staff learned a valuable lesson from this error. The doctor learned that he must write orders more clearly. And the staff learned that unusually high or low doses should always be questioned.