Lessons About Medication Errors From Baseball

In the commercial, three guys are standing around a grill, talking about baseball. One of

them quotes a stat.

Another one says, “Really? Are you sure?”

The first guy says, “I’m 99.9 percent sure.”

The third guy says, “Then you don’t know.”

I don’t remember what product was advertised. I remember the commercial because the question of certainty came up regarding a medication order.

I was reviewing the chemotherapy orders:

• Patient name and identifiers: √
•  Orders are dated with today’s date: √
•  The chemotherapy ordered is appropriate for the patient’s diagnosis: √
•  The dosage is correct: Uh oh. Wait a minute.

The total dose (in milligrams) did not equal the product of milligrams times meter squared (m2). The reason was easy to spot, however.
The chemotherapy infusion was to be administered as a continuous infusion over two days. The order read:

xxxx mg of chemo drug X m2 = xxxx mg X 48 hours = total dose of chemo drug

The doctor meant to write:

xxxx mg of chemo drug X m2/every 24 hours = xxxx mg X 48 hours = total dose of chemo drug

I was 99.9 percent sure, which means I wasn’t certain. Unlike quoting baseball stats, there is no room for uncertainty in chemotherapy administration. Interestingly, a pharmacist felt 99.9 percent certainty was good enough and mixed the cassette sitting in front of me.

To be fair, this was not the patient’s first infusion. The pharmacist mixed the chemo based on past orders. Using a previous record to predict a result in the future is the definition of betting, which works in baseball, but not so much when administering chemo.

I called the office where the order originated. The nurse on the other end of the phone pulled up a copy of the order. “Oh, he meant to write every 24 hours. If I write that and fax it back to you, will that work?”

“Yes it would,” I said. “Are you certain?”

“I’m 99.9 percent sure.”

“Certain enough to sign your name to an order?” I asked.

There was a pause, and she said, “I’ll have the doctor take a look, sign it, and fax it back to you.”

I thanked her.

The corrected order, signed by the doctor, arrived on the fax machine. The checklist was successfully completed, and the infusion started.

I was 100 percent certain the infusion was correct.

Do you ever feel like the nurse holding everything up? What’s your opinion? Would you trust your familiarity with a patient’s past orders and go ahead with the infusion? Does your work environment support nurses delaying treatment while verifying orders?