Today I got an email from a registrar whose patient I reviewed over my night shifts.
I had reviewed this man who had had a stroke and whose level of consciousness was fluctuating, making his swallow unsafe. The registrar who admitted him, had prescribed oral medications for him.
The nurse had called me to change his medications to IV. specifically, his anti-seizure medications.
I changed all his medications to IV, including his beta blockers and calcium channel blockers. These are very sensitive heart medications that slow your heart down when it’s going too fast or beating irregularly.
The registrar emailed me to tell me that these medications are never prescribed IV unless there are very specific indications or a patient is in intensive care. I had prescribed them on a ward overnight.
She informed me that thankfully, the patient hadn’t received these medications because the pharmacy does not dispense them overnight. She said that she would never prescribe those medications because the doses aren’t the same in oral as they are in IV and they could have caused a massive slowing of the heart and basically would have been fatal to the patient.
She told me not to stress about it as the patient is fine, but it’s just something to be aware of in the future.
I can’t quite explain how scary this was for me.
When I was changing his medications to IV, I hadn’t known those medications were available IV. When I saw that they were, I thought to myself, huh. That’s interesting.
But it didn’t occur to me to look up whether they could be used IV in a patient who had oral medications. What I should have done was withhold those oral medications until the patient could be reviewed the next day.
I nearly killed someone.
If the patient had received those medications, he would surely have had a massive bradycardia that wouldn’t have been easy to reverse.
I have no excuse other than I didn’t know. Which in my head translates to a level of incompetence.
I should know.
I can’t still be operating at a level where I don’t know what I don’t know. And that apparently nearly hurt someone.
I actually did cry when I read that email.
I probably should take the “well that’s how you learn” approach. It turned out fine. But I don’t think I’d ever be able to forget just how bad it could have been. Just how vulnerable someone is to the consequences of my actions.
I know I’ll be double, triple checking everything I prescribe from now on. And there’s just no excuse for getting something like this wrong.
None at all