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A doctor wrote this order for a patient with a lower respiratory tract infection:
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As he handed the multipart order form to the unit secretary, he said he wanted the first dose started at once.
The unit secretary immediately sent the pink copy of the order to the pharmacy and placed the yellow copy in a folder for the medication nurse. Then she transcribed the order onto the patient's medication administration record (MAR). When the medication nurse prepared to administer the first dose, she checked the MAR transcription against the yellow copy of the order, approved it, and started the infusion.
A few minutes later, the doctor returned and changed the order to 2 grams by writing a 2 over the numeral 1 on the original order form. No one saw him do this, and he didn't tell anyone about the change.
On the next shift, a nurse checked the doctor's order form against the patient's MAR and noted the discrepancy. She called the doctor, who explained that he'd changed the order but thought the change would have been noticed before the first dose was given. The nurse asked him to write a new order.
Luckily, the patient received only one incorrect dose because the nurse followed the routine procedure of checking all medication order transcriptions against the original orders every 24 hours. This is the best way to uncover any inconsistencies.
But doctors should be reminded to always write a complete new order (and notify a staff member) when they want to change one rather than alter an order already written.