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A patient who had rheumatoid arthritis came to the outpatient clinic for his weekly injection of Myochrysine (gold sodium thiomalate). The doctor examined the patient, then told the nurse to "give him 25 mg." The nurse gave the patient 25 mg of Myochrysine, as usual, and placed his chart aside, planning to document the dose later.
That afternoon, when the nurse was charting the day's events, she was dismayed to see the doctor had written an order for 25 mg of methotrexate, not Myochrysine. She immediately told the doctor what had happened. He explained that he'd changed the order to methotrexate because the patient's condition was no longer responding to Myochrysine. He assured the nurse that the Myochrysine wouldn't hurt the patient, but asked her to have him come back in for the correct medication.
The nurse called the patient, who returned to the clinic and was given the methotrexate.
In this instance, the patient wasn't harmed by the doctor's incomplete order. In a different situation, however, such an error could have serious consequences. So when you receive an incomplete verbal order, always clarify it (for example, "That's 25 mg of Myochrysine, correct?"). Also, wait to review the written order before giving a drug.