The title may be a little more dramatic than the actual events...but really, i could have done something very bad. good thing there are many safety guards in place to protect my patients from me :)
this morning during rounds i had 5 patients to see and came in extra early to be on top of everything. i was doing great, looked like a rockstar, had all my notes and updates organized. wrote the orders the doctor and I discussed he glanced em over and we moved on. we saw a couple more patients and then went to the doc's office to get a lecture from him. not 2 minutes in, we got a phonecall. he puts it on speakerphone [like usual] and its a nurse...asking about our order. "I just wanted to clarify the order you left for patient X, you want 60 units of long acting insulin 3 times a day? He was only on 58 twice a day before."
crap
we verbally clarified the order to 60 units twice a day. the doc wasnt mad, thank god. he just went into a speech about mistakes, how it is easy to make them, and to triple check all the orders we write. [to note, that extra 60 units would have made him hypoglycemic putting him into a coma and probable death]. We were told that from the time we write the order, 7 people see it, read it, and double check it before it is actually given...several nurses, nursing clerk, pharmacist, etc.
food for thought: "The average, major teaching hospital experiences an increase in risk-adjusted mortality of roughly 4 percent in the July-August period."
this is when new intern's [just graduated 4th year medical students] begin their residency...practicing medicine on 'their own' for the first time. granted, like this example, there are lots of things in place to keep us from killing patients...despite our best efforts. but, accidents still happen.
stay away from the hospital in July and August....
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