A long time ago in a hospital far, far away I witnessed a serious doctor error which is indelibly ingrained in my memory. I had one full year of experience under my belt, when TPTB made me one of the night shift "charge nurses." Being night charge in that small community hospital was actually akin to being night supervisor--you had to be resource person for the ER, ICU, swingbed unit, OB. Night charge was responsible for bed assignments as patients presented to the ED, infection control matters, transferring emergent patients in need of more specialized care to the regional hospital an hour away, dealing with employee conflicts and disgruntled family members and a host of other things that so unpredictably popped up, as well as the welfare of ALL 50 or so patients in the hospital--an ENORMOUS responsibility for one so young and inexperienced.
So, one particular night I was charge. One of the nurses became sick, so (in addition to being charge) I had to take over her line of patients 8 hours into the 12 hour shift. One of her patients immediately caught my attention. A frail little woman seventyish--I had actually admitted her two or three days ago. When I had admitted this woman, she had been alert, fully oriented, conversant, appropriate. She had been admitted for a GI "work-up." Now this dear little lady had very inappropriate behavior, inappropriate words, staring out into space, unable to get her to connect with reality. She had been admitted by a family practice doc in the town who had two associates. All three docs were overworked and harried and were in and out of the hospital on pt visits like greased lightening. So she had probably been seen by all three docs with very poor communication between them. Turns out she had been on a Colyte regimen for two or three days!!! Had her NPO during that entire time and on a NS drip only.
Called the doc on call, told her she had been acting very strangely and SUGGESTED that her electrolytes be checked!!! Well, it turned out her potassium was 1.8, magnesium and calcium also CRITICALLY LOW. Had her transferred into the ICU and also had the ER doc come up, check her out and write orders for her since the family practice doc on call was so slack and curlish, wouldn't come by himself. The lady never did recover. Stayed like she was, totally out of touch with reality. (Perhaps she had stroked-out due to the low electrolyes???) Family later transferred her to a nursing home, and she died a short time afterwards. She and her husband had just moved to the area for retirement, to be close to their daughter. What a tragic thing to happen!!! All over a stupid bowel prep. I hate Colyte to this day, as it is very dangerous, will cause electrolytes to leach out in vulnerable patients. Of course, the hospital and FP doc covered it all up and the family never did find out what actually happened. I never blew the whistle because I knew they would turn it all on me if I did (afterall, it is ALWAYS the nurse's fault).