The Dumbest Orders in Patient Charts

The medical field, especially the nursing and emergency care sectors, is filled with stories of blunders that occur due to human error or misunderstanding. These mistakes can range from harmless oversights to potentially life-threatening issues. Here are some humorous yet cautionary tales from experienced nurses and emergency medical technicians (EMTs).

Typographical Blunders

In one incident, an emergency room (ER) doctor accidentally typed "Call your mother" on the discharge order form instead of the correct message, "Call your doctor in 2 days."

Although the nurse brought the error to the doctor's attention, it still serves as a reminder about the importance of careful documentation and double-checking discharges to avoid such embarrassing and potentially confusing scenarios.

Contradictory Information in Charts

Another common mistake in patient charts involves contradictory information regarding medications. For instance, an EMT reported seeing a medication listed as an allergy in one section of the chart, while in another, the same medication is prescribed daily. A particular example involves aspirin.

This discrepancy underscores the need for thorough verification and update of patient records to ensure consistency and prevent adverse effects from accidental medication administration.

Unconventional Prescriptions

When considering medications, it’s important to consider their intended use and potential risks. An EMT, who had recently become a new parent, recounted an unusual prescription provided by a doctor who prescribed a Coca-Cola with a Hershey's chocolate bar for post-surgical headaches. Crying, "I had a C-section and was suffering from excruciating headaches that only went away when I was flat on my back. The candy did not provide any relief; I still don’t know what he was thinking."

This story highlights the importance of clear and rational medical decision-making, especially when prescribing pain management.

Critical Orders Misunderstood

Specialized units like Cardiac Intensive Care Units (CICUs) have strict protocols for different types of orders. A nurse recounted an incident where a new night resident ordered "stool softener STAT" for a patient going into and out of ventricular tachycardia (VTach). While stool softeners can be beneficial for constipation, the nurse reasonably disregarded this particular order, opting to consult with the intensivist regarding more appropriate treatment (e.g., amiodarone).

This highlights the need for nurses to prioritize patient safety and to seek expert guidance when faced with seemingly random or unnecessary orders.

Misattributed Patient Orders

Another nurse experienced frustration when orders were accidentally sent to a different doctor due to unclear provider patient assignment. One attending physician repeatedly reminded nurses that the orders were not for their patients, which ended up being documented in the patient's permanent medical record. This mistake resulted in orders stating "Notify RN: This is not our patient," further emphasizing the critical need for clear communication and patient records management.

This story serves as a cautionary tale about the importance of accurate documentation and the risks of miscommunication in healthcare settings.

Unexplained Orders

In a Cardiac Intensive Care Unit (CICU), a new attending physician placed an order for "call for abnormal values" with no further explanation. For this nurse, this unexpected order was interpreted as an order to call the doctor every 5 minutes. This underscores the need for clear and detailed instructions to avoid misinterpretation and ensure proper patient care.

These anecdotes not only provide insight into the daily challenges faced by medical professionals but also highlight the necessity for robust communication, clear documentation, and the importance of double-checking in high-pressure environments like the ICU.

Conclusion

Despite the various systems and checks in place, human error still plays a role in healthcare. By sharing these stories, we aim to bring attention to the importance of clear and error-free documentation, timely communication, and the critical role of nurses and medical professionals in ensuring patient safety.