The Virtue of Regimentation

The other night at work, a very astute nurse came to me with what appeared to be a medication error. The dosing seemed strange so the resident and I sought to find the reason for the anomalous dosing. Here's what we found: When the patient was initially admitted to the general peds floor for respiratory distress, the dose of this home medication was ordered as 3mg. Now, looking through the patient's discharge summary from his previous stay in the NICU, it appears that he was sent home on 0.3mg which was the recommended dose for his weight. For reasons completely unrelated to this medication, this patient's condition worsened so that he was transferred back to the NICU (he is a former premie, hence his previous stay with us) after 3 days and when this medication mishap was discovered, had been in our unit for another 3 days. In other words, he had been given this 10 fold dose of medication for a week while in the hospital.


It is tempting to look at the original admission order writer and place blame there. But, that is an oversimplification of the checks and balances that are supposed to be in place in hospitals to prevent medical errors. The collective "we" failed this patient on many levels. This dose got by the doctors, the nurses, the pharmacists, the computer ordering system on a daily basis. For a week. Why did this particular nurse decide to check the dose before giving the medication that night? Was she just being diligent? Was she following a protocol that says that nurses need to review medication doses periodically? I have no idea. But I do know this. Mistakes happen, we are human after all. Therein lies our responsibility as the deliverers of healthcare to police ourselves. Yes, its nice to expound on the 'art of medicine' and to delegate our brains as the keeper of all minutiae pertinent to our respective fields and maybe even deem ourselves a bit above 'following the protocol'. But is that best for our patients?


Atul Gawande, a physician writer and a man I credit for opening my mind to so many things in medicine, wrote a fascinating article about the value of checklists in the ICU and the resistance to implementing such a simple change. Checklists, he postulates, are a way to assist memory recall for mundane matters that are easily overlooked in patients undergoing more drastic events. In our patient, his home medication had nothing to do with his breathing issues and his subsequent transfer to the ICU. But, it was an error nonetheless. There are multiple checkpoints in place to catch these errors before they ever reach our patients. But, checkpoints and checklists are only as good as those enforcing them. Kudos to the nurse who that night, considered diligence a worthy endeavor.