Yesterday I had a diabetic old man, who had a wife there too. The doctor had come in before my shift and written dc orders. His 7 AM blood sugar was 54. We gave him orange juice. I called the resident to notify him that he had gotten the 45 units of Lantus at 2200, and his blood sugar was 54, and did he want to re-evaluate his diabetic DC meds? After that, the lab called with a serum blood sugar of 40 with the AM blood work.
Then I noticed that the pt also had a 10 AM Lantus dose, also 45 units. I held that as well as his Glyburide in anticipation of the doctor. Glancing through the orders with the doctor, I found only the 45 units Lantus at bedtime order, it looked like there had been a med error in transcription.
Throughout this, I had kept the pt and his wife informed that I was going to discuss this with the doctor, that maybe he would want to adjust the diabetic meds before discharge. I ascertained in my conversation that the pt was well aware of the symptoms of low blood sugar, and his wife was really on top of everything in her wifely duties (she was 13 years younger than him).
I informed the charge nurse that there had been a med error, and we went through the orders again. She deduced that both the pharmacy and the charge nurse who had signed off the orders had misread 45 units of Lantus at 'Bedtime' as 'BID twice'. On looking at it, it was sloppy handwriting that led to this error. She was going to report this.
So, I went to the patient and his wife and informed them that he had gotten too much insulin due to an error in transcription, and that there would be no change to the insulin order on DC. The wife said that errors happen and that there was no harm done. I had already established a good rapport with both the husband and wife, so it was easy to talk to them about what had happened, they were better informed and the pt was DC'd home to the care of his loving wife.
"I have been told not to tell a pt. about mistakes made by the doctor. I had a doctor once make a mistake concerning a surgery, but I never told the pt since I felt it was the MD's responsibility to explain it."
wymnwise
70 Posts
"I have been told not to tell a pt. about mistakes made by the doctor. I had a doctor once make a mistake concerning a surgery, but I never told the pt since I felt it was the MD's responsibility to explain it."
Hmmm. If the doc does not tell; you should.