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Fam Pract Manag. 2005;12(3):72

Vitamin V

Maria, a middle-aged, spirited Hispanic woman and one of my favorite patients, came into my consultation room and immediately closed the door. When a patient does this, I know the conversation is going to be personal, usually about sex.

“Dr. Brown,” Maria began, “I’m going crazy. My husband, Carlos, won’t make love to me anymore. He says he isn’t interested, but it’s because he can’t perform like he used to. I told him I would divorce him if he doesn’t get help.”

I remembered that, the year before, her husband had come in for a visit and had a difficult time talking about his sexual dysfunction. It’s a difficult subject for many men but particularly Hispanic men, whose culture puts a high value on machismo. So I made it easy for Carlos and gave him some Viagra samples. “They worked,” Maria said, “but Carlos is too proud to come back and ask you for more.”

“No problem,” I told her. “Here’s another sample pack. When it runs out, maybe he’ll be ready to talk.”

A month later, Maria came back with a progress report. “The pills worked,” she said, “but I’ve run out.”

“Why don’t you send Carlos in and I’ll give him a prescription?” I asked.

“He doesn’t know what he was taking,” Maria said. “He would be humiliated if he knew I came here asking you for help, so I told him they were vitamins. He never looked; he just swallowed them. It was great while the pills lasted, but now I’m afraid he’ll try and fail and embarrass himself.”

I was horrified. “Maria,” I said, “I can’t allow you to give Carlos a drug when he doesn’t know he’s taking it. You have to tell him what you’re doing, or I will. Just how long had you planned on keeping up this deception?”

“That depends on how many more pills you have in your closet,” she said sheepishly.

A transcription error

I was enjoying a weekend away with my family when, after an afternoon hike, my daughter informed me I had a message on her cell phone. Not one to carry a cell phone or beeper, I gave her number to the hospital operator in case of emergencies. The call came from the nursing home. I couldn’t imagine what was up.

“Dr. Brown,” the nurse said, “I just sent Gina Underwood to the emergency room. Her leg was mottled and cold, and she was in a lot of pain.” Gina, an 83-year-old long-standing patient, was at the nursing home to convalesce from an embolectomy to her brachial plexus. She had been in marginal health on a multitude of medications, including Coumadin for atrial fibrillation, when she had a massive gastrointestinal bleed caused by a bleeding diverticulum in her transverse colon. She survived a hemicolectomy but began to rebleed when she was put back on Coumadin. When the hospitalist caring for her backed her off, she threw the clot.

She was evacuated by air to a tertiary care center, where her referral surgeon removed the clot, saved her arm and meticulously monitored her bleeding time, using a combination of heparin and Coumadin. When she was shipped back to the nursing home to recuperate, her international normalized ratio (INR) was 1.7, almost therapeutic, and she had been given a subcutaneous injection of Lovenox for the road. On Friday afternoon, I had admitted her and ordered 5 mg of Coumadin per day, which had been a stable dose for her for years, and a protime test Monday morning. It was the following Saturday when the call came through, and I realized I had never received the report. Distressed, I immediately called the hospital lab to learn that Gina’s INR was now 1.13. I thought I had really blown it and began to wonder if I had even written the order for the test.

Gina was again air-evacuated to the hospital but to a different surgeon, who proceeded to take a 35 cm clot out of her right femoral artery, which saved her leg. I was relieved for Gina but beat myself up for the rest of the weekend.

The first thing Monday morning, I went back to the nursing home to look at Gina’s chart. Then I learned the truth: I did write both orders, but they had been transcribed incorrectly as “5 mg of Coumadin per day until Monday.” The protime test, although ordered, never was done because there was no tech to draw it on Monday and no one thought to do it the rest of the week. Not only had Gina not had her test, she hadn’t even gotten her drug. No wonder her INR was “normal.” She wasn’t under-Coumadinized; she had no Coumadin on board at all.

Although this catastrophe wasn’t my fault, I felt badly about it and vowed to reinstitute my daily to-do list, which would remind me to follow up on patients like Gina. Never again would I let my orders be undone by a simple transcription error.

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