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小松鼠: 引以为戒--值班犯了个愚蠢的错误
作者:USMedEdu
发表时间:2007-09-28
更新时间:2007-09-28
浏览:1770次
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squirrel07 (xiaosongshu), 信区: MedicalCareer
标 题: Stupid mistakes
发信站: BBS 未名空间站 (Fri Sep 28 12:55:50 2007)

I am in my second year of residency in IM. Yesterday, I did a consult as an
endocrinologist (elective). One pt had DM type I, from NH because of acute
stroke. BG was 300-400.not on insulin after admisssion. Used to take lantus
QHS and humolog SS.

I went there, looked at the chart, figured that the pt took Lantus 100 QHS
based on the med reconciliation form, H&P and RAN from resident and the ER
chart. So I discussed with my attending. Ordered 50units of lantus and put
on insulin drip for tight control. Second day the attending went to see the
pt and noticed that his sugar was low during night time. wondered whether
the insulin drip was done correctly or not. Accidently he saw the order from
the original NH chart: lantus 10 units QHS....

Nothing terrible happened. But it could have caused serious problem, if.....

I was so mad at myself that I didn't bother to look for the most original
sheet...

We are all learning... We are all humans, so we do make mistakes.. But still
...

Anyway, tell the story to you and hope you all learn from my mistake.

--

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