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Nearing the end of her 18-hour work shift, a resident sees a patient with extremely high blood glucose levels. She writes the patient a prescription
Nearing the end of her 18-hour work shift, a resident sees a patient with extremely high blood glucose levels. She writes the patient a prescription for insulin; however, in her exhaustion, she closes her “U” (for “units”), and it looks more like an extra zero. As a result, the pharmacist dispenses an insulin dose that’s ten times stronger than the patient needs.To prevent this problem from happening again, which of the following would be the best course of action?Develop a system that prevents messy handwriting from causing miscommunication that leads to error.Require both the resident and the pharmacist to take additional training.Ensure that no prescribing physician is ever tired or distracted.Punish the resident and the pharmacist for their careless actions
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