This is what happens when I find a rhyming dictionary online. Sorry.
Patient has very low whatever for like a week and we can't figure out why. We keep supplementing the whatever but the level still stays really low. All sorts of working theories, infections, rare complications, things that no one can really figure out.
And then I'm reviewing the chart, just checking my intern's note, and I happen to notice one of her medications.
Not a medication we gave her, but a medication she's been on, for weeks. A standing order. (She's been in the hospital for a while.) Given three and a half weeks ago by another doctor, filling in for someone else's overnight shift.
A medication it might have made sense to give once, depending on what was going on, but didn't make a lot of sense to give every day for weeks, especially when the patient didn't need it.
We get lots of justification for long shifts by saying they want to minimize handoffs and have the same doctors following patients for the whole day. But nothing we do really minimizes the handoffs when every 2 weeks or every 4 weeks, the entire team changes-- attending, fellow, resident, interns, students. You come on to a team and get 15 patients you've never met before, and, sure, you go meet them all, and you read their charts, but you also assume that whatever plan has been put in place is a plan that someone was paying attention to. So you don't just come on and discontinue every standing medication order. You assume that the medications the patient is taking are medications that someone wants them to take, and so while you're always looking, and certainly with a change of condition, or a change of plan, you're reassessing, but the background assumption is that what the patient has been taking every day for weeks makes sense and is something they're supposed to be taking.
The order should have been for one dose, not a standing order to take it every day. Fortunately, no permanent damage, we discontinue the medication, level of whatever will come back up, and she should be as fine as the rest of her condition enables her to be. But, still, that's weeks of poking and prodding and testing and risking potential longer-term issues because as a collection of doctors, no one noticed. The previous team assumed the night team wasn't adding a standing medication order, and so didn't notice when the next day, the patient had one more medication in the chart. We come on and replace that team, and we assume the medication is being given for a reason. Or we don't spend a lot of time worrying about it, since the patient's condition isn't changing. Until we notice a problem and go back and... oh, this isn't a rare and complicated issue, this is a powerful medication being given unnecessarily for weeks because someone checked a box by mistake.
In most jobs, I'm certain stupid, minor, tiny mistakes get made all the time, and they're not even on the radar screen. Books are published with typos, restaurants send out food that's too salty, lawyers misplace a document. But the stakes here are real, even for mistakes that are too small to notice. I spent a good part of the night running through this one-- why we didn't catch it, why it took a week to figure it out. We have 15 patients. By the time I really know them, I'll be moving to a different rotation.