ISMP Safe Medicine May/June 2007, Volume 5, Number 5. ©2007 ISMP
Brand name medicines appear in green;
generic medicines appear in red.
An inquisitive patient is a safe patient. Persistence pays off
If you are hospitalized, nurses will typically give you the medicine your doctor has prescribed. But if the medicine the nurse brings to you doesn't seem right, it might be that an error has happened. You may be hesitant to speak up about the potential problem. You may believe your doctor and nurse know more about medicine than you do. But in some cases, your instincts may be right, as in the example that follows. When a hospitalized patient with diabetes suggested that 85 units of insulin was too much, the nurse rechecked the doctor's orders and the patient's medicine record. Both showed that 85 units had been prescribed. The patient still felt the dose was wrong, so the nurse called the doctor. It turned out, the patient was correct. When the patient was first admitted to the hospital, the doctor had looked up the patient's insulin dose in her medical record from a previous hospital admission. He had then prescribed the dose - 85units - listed in the medical record. But the record in the doctor's office showed that the patient's insulin dose had been lowered since the last time she was in the hospital. In this case, the patient's expressed concerns led to the discovery of the error. But if a patient speaks up about a concern and an error is not found right away, he or she should persist if something still feels wrong. A tragic example follows in which a patient's concerns about her medicine were not fully checked.
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