The missed heartbeat
as seen on ECG
Today most of my patients are hypertensive and they come according to their respective appointments. They dutifully sit down in the waiting area for their names to be called. My nurse would search for their blood investigation results (if any) and attach them to their medical records. Due to the large number of cases, I would only know the patients by their faces and not by their names. Moreover I have always expected my nurse to be vigilant and ensure patient-record concordance.
A name was called after a few patients and a lady of 52 came in. I have of course seen this patient a few times but for the life of me I would not know what her blood pressure trend has been unless I looked at the record.
After the usual greetings and questions on her health, I proceeded to check her blood pressure(BP) and pulse rate (PR). I found the BP to be higher than the last visit two months ago and her PR was a lot slower than before as well. I checked the medications, it was not a beta blocker which could have slowed down her pulse rate. I then asked her whether she had been under a lot of stress lately since she had admitted earlier that she had been taking her medication regularly. She said yes, there was this issue with her husband that was making her stressful. Hmm..
I looked at the blood results, the parameters were excellent. The cholesterol and the fasting sugar level were perfect. I congratulated her. Wanting to know her lifestyle secrets, I asked her about her meals and what sorts of food items she liked and whether she exercised regularly. She said she hardly had time for regular brisk walking and that she liked drinking goat's milk, eating meat and fried foods and I was like wondering how she could produce such excellent biochemical blood indicators with such habits! Good genes?
I wrote out the prescriptions and told her to find ways to remove her stress which could have contributed to her higher blood pressure during this visit. I was still uneasy about this encounter and was rather reluctant to tell her to continue with her lifestyle.
The next patient was called in and as I was asking about her general health, someone knocked on the door and true enough she was the previous patient and she had been prescribed the wrong medication!! Her medical record was exchanged with the patient in front of me. What a blunder! This near mishap could have turned into an avoidable medical error.
A good system of record matching is already in place, it is the human error which needs to be addressed. A new young and inexperienced nurse does not help matters but she is learning fast. On my part, I need to trust my clinical judgement more the next time.
By the way, shouldn't I be greeting my patients by name ?
as seen on ECG
Today most of my patients are hypertensive and they come according to their respective appointments. They dutifully sit down in the waiting area for their names to be called. My nurse would search for their blood investigation results (if any) and attach them to their medical records. Due to the large number of cases, I would only know the patients by their faces and not by their names. Moreover I have always expected my nurse to be vigilant and ensure patient-record concordance.
A name was called after a few patients and a lady of 52 came in. I have of course seen this patient a few times but for the life of me I would not know what her blood pressure trend has been unless I looked at the record.
After the usual greetings and questions on her health, I proceeded to check her blood pressure(BP) and pulse rate (PR). I found the BP to be higher than the last visit two months ago and her PR was a lot slower than before as well. I checked the medications, it was not a beta blocker which could have slowed down her pulse rate. I then asked her whether she had been under a lot of stress lately since she had admitted earlier that she had been taking her medication regularly. She said yes, there was this issue with her husband that was making her stressful. Hmm..
I looked at the blood results, the parameters were excellent. The cholesterol and the fasting sugar level were perfect. I congratulated her. Wanting to know her lifestyle secrets, I asked her about her meals and what sorts of food items she liked and whether she exercised regularly. She said she hardly had time for regular brisk walking and that she liked drinking goat's milk, eating meat and fried foods and I was like wondering how she could produce such excellent biochemical blood indicators with such habits! Good genes?
I wrote out the prescriptions and told her to find ways to remove her stress which could have contributed to her higher blood pressure during this visit. I was still uneasy about this encounter and was rather reluctant to tell her to continue with her lifestyle.
The next patient was called in and as I was asking about her general health, someone knocked on the door and true enough she was the previous patient and she had been prescribed the wrong medication!! Her medical record was exchanged with the patient in front of me. What a blunder! This near mishap could have turned into an avoidable medical error.
A good system of record matching is already in place, it is the human error which needs to be addressed. A new young and inexperienced nurse does not help matters but she is learning fast. On my part, I need to trust my clinical judgement more the next time.
By the way, shouldn't I be greeting my patients by name ?
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2 comments:
Hahaha...good story!. No matter how good a system is in placed, there are still subject to human errors. But we are improving everday. Didn't we?
Dear AC,
Long time no see!
Yes I learnt from that particular experience and now I take time to look at each of my patient's name..
We can only improve if we kept on monitoring the risks which should have been identified and listed out.
This monitoring mechanism is applicable to all industries.
But human errors are notoriously subject to factors such as lack of concentration, boredom and taking things for granted.
We are learning everyday though.
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