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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Written By Eric Christianson

June 5, 2016

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