Confusing Orders, Lack of Clinical Thinking = Bad Outcomes

I’ve worked with hundreds of nurses.  Most of the nurses I’ve worked with are in long term care.  I wanted to touch on an issue that I see happen once in a while.  I’ve seen a number of mistakes with hold orders or parameters on orders.

A 61 year old female has a past medical history of diabetes.  She has been on insulin for years and is residing in a long term care facility.  Her course of diabetes has been a rough one.  She has been followed by endocrinology and is considered a “brittle” diabetic.  Essentially patients with brittle diabetes can have major fluctuations in blood sugars that are hard to predict and very difficult to manage.

She has a unique order for nursing staff check blood sugar in the middle of the night as she has had a history of getting hypoglycemic at this time.  There is a hold order for her next insulin dose if this blood sugar is less than 70.  (It was a very confusing order and this patient was very complex.) What wasn’t stated was that staff is supposed in the event of hyperglycemia.  Her blood sugar was checked and was over 500.  Staff was following the orders of the endocrinologist literally and did not take action with the elevated blood sugar, resulting in diabetic ketoacidosis and hospitalization.  Literal interpretation of orders without application of clinical common sense can put our patients at risk.  Always be thinking and take action if something doesn’t seem right!

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  1. K. Bezz

    Great case example Dr Christianson. This reminds me of the frequent errors I see from my collegues everyday when they write an Insulin sliding scale: more often than not they have the same BG value in two spots. Many write an insulin sliding scale like this: BG on FS < or = 100 -150 nothing. 150-200 2 U Regular, 200-250 4 U Reg., 250-300 6 U Reg. If the BG on FS (Blood Gliucose on Finger Stick) is 150 does the nurse give any insulin or do nothing? If the FS BG is 250 is the nurse to give 4 U or 6 U of Regular insulin? Instead we have to be careful to make each range with unique numbers: 151-200 BG on FS: 2 U Reg, 201-250 4 U Reg., 251-300 6 U Reg, 301-350 8 U Reg. Etc. Thanks. Insulin Units here were just an example. I don't usually write a Sliding scale for insulin but instead get called for every FS and decide on an individual basis how much insulin to give.
    Thank you for your continued efforts to educate us in clinical pharmacology Dr Christianson.

  2. Linda McMahan, R.Ph., CGP


  3. Felipe

    Nicely done. Keep the clinical pearls coming! I’m a P4 in Atlanta (Go Dawgs!) and I have learned quite a bit from your articles

    • Eric Christianson

      Thanks Felipe!


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Written By Eric Christianson

June 5, 2016

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