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A 12-year-old child suffering from asthma was admitted to a pediatric unit. His doctor wrote several orders, including this one for sustained-release theophylline:
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The nurse who reviewed the order knew that Theo-Dur is available in 200- and 300-mg tablets, so she wasn't sure how to interpret it: Did the doctor want her to administer 1 1/2 200-mg tablets to make a total dose of 300 mg, or did he want her to give 1 1/2 300-mg tablets, to make a total dose of 450 mg?
The nurse called the doctor at home and asked him to clarify his order. He said he wanted the patient to receive a dose of 300 mg. He didn't know a 300-mg tablet was available. So the nurse canceled the order and wrote a new one, which the doctor signed the next day.
By questioning an unclear order, this nurse prevented a potential overdose of theophylline. So whenever you see an ambiguous order, don't hesitate to question it. If you guess at the meaning, you may guess wrong. In medication administration, it's better to be safe than sorry.