* * Anonymous Doc: Medication; No notation; Complication; Pure frustration; Utter incoordination

Wednesday, January 25, 2012

Medication; No notation; Complication; Pure frustration; Utter incoordination

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.


  1. I know from experience that these things happen, I've once nearly overdosed a patient on a truly simple and harmless type medication. Except that it isn't as harmless if you get the dosage wrong by a factor of 10 or a 100.
    I wonder if you have a system that requires you to report errors such as that? In every hospital in my country we do. It's a system where anyone (literally from the cleaning lady to the professor) can file a form reporting the mistake. Even the simplest things get reported. The beauty of it is that it isn't at all judgmental. No one blames anyone, because most things are things that could've happened to anyone. You know you could've mistyped, or miscalculated, or simply forgot to put a certain instrument in a kit. Human errors are common. The really positive thing is that in theory, these reports add up to a way to improve the system, so that it will not allow human errors anymore. I'm not sure if in practice, the results really are what they're intended. But I do think that the awareness is a major step in getting rid of some/most/all errors. Plus it's nice to work in an environment where the work ethic is to report errors without placing blame. It's easier to man up to your own mistakes, too.

  2. Very sensible post altogether, but one thing makes me wonder... why does the attending change? I get resident and student rotations, but isn't the attending sort of a permanent fixture of a certain floor and the actual doctor of those patients? Who follows them for whatever their condition is in clinic, to whose care they are admitted, takes ultimate care of them in the hospital and then provides follow up after discharge? Cause that's how it works here, and it makes certain that every patient has a doctor who knows what is going on and can fill in the incoming residents.

    Oh, and as for not noticing for a while... we have a rather lovely medication order system which is a click of the mouse most of the time, but every given number of days (the exact number depends on the department), you have to type the whole name and dose and route and whatnot for each medication. On some floors it's weekly, on some it's every two weeks, in ICUs it's daily, but either way, there's a set occasion for each patient where you have to sit down and take AMPLE time for their meds, and you can't click your way through them. I find that when I have to retype a whole list of a bazillion meds, I tend to discontinue or change the dosing of a lot more meds than on the other days. Sort of a useful time-out, I suppose.

  3. This is why I will always have a job.

  4. Regarding non-discontinuation of meds... I had one episode about 7 years back. I was working the overnight shift in what at the time was the busiest pharmacy in the state. Someone had called in wanting "all his refills". Rather than just faxing the whole list to the doctor, I looked through them to see what was what. There were a buncha BP meds, some of which had been recently increased in dose . . . and one vasopressor. (Can't remember which one at this point, maybe dobutamine or midodrine.) Going back through the history, it had been prescribed once for a seven day period, then renewed for 30 days, every month for the next three months.

    I called the patient back and asked him if he knew what that particular med was prescribed for. He had no idea. I told him this drug was intended to *increase* blood pressure. Then he remembered that he'd had an episode of hypotension, several months back, and this might have been given him to raise it back up. I told him that taking this together with beta blockers and other BP meds would have the same effect as putting an engine at both ends of a train and pulling in opposite directions, and maybe this is why his BP meds had been increased so much.

    Then he wanted to know, if this was the case, why did we keep renewing it? Uhm, maybe because you kept calling in and telling us to? Following which, some overworked pharmacist on his way to filling a couple thousand scripts in a day hit the button to automagically send in the refill request, and some equally overworked doctor (or more likely, someone in his office) clicked on the Approve button, and nobody actually ever looked at the damn script to see if it was reasonable. And did this for three months running.

    This is one reason why I now refuse to fill "all my refills". No sir/ma'am. You tell me which ones you need, and then I won't be getting yelled at for filling something you didn't want or aren't taking anymore.