| Contents | Previous | Next |
A patient who'd been taking prednisone at home was hospitalized for surgery. Because the patient couldn't take anything by mouth after surgery, his doctor ordered hydrocortisone, 100 mg I.V. daily, to replace the oral prednisone. The patient received this for several days.
Later, when the doctor decided to restart the prednisone, he wrote the following order:
|
|
The unit secretary interpreted this order as prednisone, 20 mg, every 8 hours and transcribed it that way on the patient's medication administration record (MAR). The patient's nurse, who checked the transcribed order, interpreted the doctor's handwriting the same way and cosigned the transcription.
At 4 p.m., the evening medication nurse gave the patient the first scheduled dose of prednisone. When she charted on the MAR what she'd done, she noted that the patient had previously been receiving 100 mg of hydrocortisone daily. She knew that prednisone was about four times more potent than hydrocortisone, so she thought it unusual that the prednisone dosage was being increased.
The nurse checked the doctor's original order. She interpreted it as q 8 a.m.-not q 8 hr-and called the doctor to confirm her interpretation. Yes, the doctor said, he wanted the prednisone to be given once daily, at 8 a.m.
This patient was fortunate that the medication nurse caught the erroneous transcription when she did. Otherwise, he could have received an overdose of prednisone indefInitely, leading to immunosuppressIOn.
Of course, the error could have been prevented if the doctor hadn't used the abbreviation q 8 a.m. to mean 8 a.m. daily. Even so, the error still could have been caught if the patient's nurse had noticed the unusual increase in dosage when she was checking the transcription:
To prevent a similar error from happening on the unit where you work, check carefully whenever you see an abbreviation for daily. Such abbreviations have led to a variety of errors.
For example, the abbreviation OD (for once daily) has been misinterpreted to mean right eye .. The abbreviation q .d. has been misinterpreted as q.i.d. when the first period was seen as an i. When q hs has been used to mean every day, at bedtime, it's been misinterpreted as q hr-every hour.
Besides double-checking the order when you see one of these abbreviations, always write out the word daily yourself. Finally, be sure to confirm any radically increased, decreased, or otherwise altered dosages when transcribing or checking medication orders