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A patient scheduled for an abdominal hysterectomy was admitted to an obstetric unit because the surgical unit was being renovated. The evening before surgery, the surgeon, who routinely ordered heparin prophylactically for his patients, wrote this order:
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The observation nurses, who weren't familiar with the surgeon's routine, interpreted theorder as "heparin5,000 units, subcutaneously, every 2 hours prior to surgery 5,000 units, subcutaneously, every 2 hours prior to surgery." Although the nurses and their supervisor questioned the high dosage, they didn't call the doctor. They gave the patient 5,000units of heparin every 2 hours throughout the night.
At the morning change of shift, the oncoming supervisor also questioned the order. But when she checked the patient’s chart, she interpreted the order differently (and as the doctor had intended): 5 ,000 units of heparin to be given subcutaneously 2 hours before surgery
The supervisor quickly notified the doctor. He canceled the surgery and ordered laboratory tests, which showed a prolonged activated partial thromboplastin time (PTT). He rescheduled the surgery for the following day, and the patient withstood it with no complications.
This dangerous and costly error could have been prevented if the doctor had used "s.c. "-the accepted abbreviation for "subcutaneously"-instead of "sub q." The nurses who read his order saw "sub q2h" not "sub q 2h" and interpreted the "q" as "every." And though they did question the order, they didn't call the doctor or a pharmacist or check a drug reference, which would have confirmed that 5,000 units of heparin every 2 hours is a most unusual order.
So when you transcribe an order for a subcutaneous injection, use the accepted abbreviation. If you see "sub q" written on an order, look closer. You may spot an error in the making.