| Contents | Previous | Next |
A nurse took a telephone order for insulin, then transcribed exactly what she heard:
|
|
The patient, a newly diagnosed diabetic, was given 18 units of insulin immediately-and another 18 units 8 hours . later (erroneously). A blood specimen was drawn when the first dose was given. The error was discovered when the patient questioned the second injection, and the nurse checked the order with the doctor.
Of course, the doctor had wanted the patient to receive one dose of insulin immediately, and a blood specimen drawn 8 hours later to assess the dose's effect. The extra dose didn't harm the patient, but he did have to be hospitalized another day so the doctor could determine his optimum insulin dose.
This error points out why telephone orders should be limited to emergencies. When you do have to take an order by telephone, though, be sure your transcription makes sense. To lessen the confusion in this instance, for example, the nurse taking the order could have specified a time for the blood specimen to be drawn. And she could-indeed should-have avoided the word stat. No wonder the blood specimen was drawn immediately.
The nurse implementing the order could have prevented the error by analyzing what she was doing. In this instance, drawing a blood specimen to measure glucose level when the first dose of insulin is given-then administering a second dose 8 hours later without drawing another specimen-makes no sense.
Don't take telephone orders if you can avoid it. But if you must take one, read the transcription back to the doctor first, then to yourself, to make sure it's perfectly clear. And if you must carry out a telephone order, be aware of its potential danger. Examine the order thoroughly before implementing it.