The Yale Journal for Humanities in Medicine

Home | About | Table of Contents| Links | Subscribe

The Error
(continued)

* * *

The clinic was crowded that day. I saw three more patients and decided to finish my electronic progress notes later. I went upstairs to the medicine wards to begin my night on call, covering for the interns who were leaving at five and coming back at six the next morning. Sometime around ten o’clock, while typing my notes one by one, I came back to Morgan’s prescription.

That’s when I saw the error. 10 milligrams of Hytrin? Not 1.0? I grabbed my pocket pharmacy book and brought it to within two inches of my face. Frantically flipping pages I found Hytrin and checked the dose, something I had not done in the clinic. 1.0 was correct, but my prescription said 10. 10 milligrams of Hytrin would topple a buffalo! Far too high to start with. Morgan would surely pass out, I was certain of it. I needed to find him and stop him from taking the medicine. Perhaps he hadn’t picked it up yet? I telephoned the pharmacy, but they had already filled the prescription. I called the shelter and spoke with a receptionist.

“Morgan Davis? Hold on a minute. Yeah, O.K. Now what was that message again?”

“Tell Mr. Davis that Dr. Simpson called and the prescription I gave him is wrong. He shouldn’t take any of it.”

“OK, I’ll tell him. Goodnight.”

I jabbed my fist into my forehead. What had gone wrong? Why hadn’t I double checked the dosage when staring at the computer in clinic? Justifications spring into view almost as quickly as I asked the question. I was in a hurry. I was behind. I trusted the computer. I hit TAB too quickly. The attending was waiting. Morgan was in a hurry too. His aunt was double parked.

And questions: Did I see a decimal point where there was none? Shouldn’t a pharmacist flag ten milligrams as an improper dose and call me? Why didn’t I take out my little pharmacopeia?

It was the computer’s fault.

It was the pharmacy’s fault.

It was my fault.

My error.

Never before had the distance between myself and a patient been so painful. Morgan’s shelter was probably within twenty blocks of the hospital, but it may as well have been across the ocean.

“If only I could leave the hospital,” I thought. Leave the nurses and patients behind. Take to the street to find this trusting four hundred pound black male. Heavy thoughts began taking shape in my mind, binding me like an anchor chains a boat at sea. What if he passes out on an empty street, unable to call for help? What if the blood rushes to his legs and causes brain damage? This was too important to leave to some anonymous receptionist at the shelter. I needed to find Morgan tonight, to minimize what harm I feared was already done.

In a screen with insurance information was a second telephone number and a woman’s name, Ms. Jasmone. The aunt waiting outside in the car earlier? I dialed, disregarding the late hour.

“Hello?” She had the voice of the aunt I imagined. Patient enough to drive her homeless nephew to his doctor. Kind enough to answer politely no matter how late the telephone rang.

“This is Dr. Simpson from the community clinic calling. I am trying to find Morgan Davis, a patient who came to see me this morning. Might you be his aunt?”

“Yes, I am. But Morgan doesn’t live here.” There was a healthy dose of suspicion in her voice now. I needed to get to the point.

“I’m worried about Morgan because the prescription I gave him today was wrong. I made a mistake in the dosage, and there are side effects that could be very, very dangerous. Do you know how I can reach him and tell him to stop taking it?”

Ms. Jasmone offered to drive by and give Morgan the message. I thanked her for being so gracious, but as I hung up the phone a new wave of dread began to wash over me. My stupidity had put Morgan at risk, and that was a bitter pill to swallow. I tried to stem the tide of recrimination, telling myself that the error is first about Morgan, and his safety, not about myself and my abilities. On the medical wards I have prescribed hundreds of medications, thousands of times over the past five months. In my own out-patient clinic I care for forty U.S. veterans without difficulty. There will be time to evaluate myself later, I mumbled. For now Morgan’s safety was the only thing that mattered.

But in the world of trail lawyers and defensive medicine, the instinct to cover my tracks, to protect the clinic and myself from liability, was like a shadow on the wall, at the back of the cave, present but not yet in clear view. I swallowed my self-protective notions and wrote down, honestly, what had occurred. In my note I described the mediation error and my attempts to contact Morgan. I wrote down the correct dose, lest someone else in the clinic receive a call from Morgan or his aunt. I gave telephone numbers and names, in case it fell to another intern to follow up. I forwarded a copy of the note to my attending, so he would know what was going on.

The next day was intern switch day, and the clinic would be far behind me when it was over.

* * * * *

Twenty two hours, four admissions and eleven new patients later, I finally made it home. Switch day is exhausting, but for an intern exhaustion and excitement often go hand in hand. A new service means a clean slate. New patients, new personalities, and new diseases to learn about.

But one old patient was still very much on my mind. I had yet to reach Morgan personally, and still was unsure if he was all right. I hung up my white coat in the hall, washed off the hospital with a quick shower, and reached for the telephone. Morgan’s aunt answered at her home number.

“Hello?” Her voice was familiar, comforting.

“Hello, Ms. Jasmone? This is Dr. Simpson calling again.”

“Oh doctor, I went over to Morgan’s house real early the next morning, but he had already taken that prescription.” I was listening for a note of relief, or despair, in her words, but found neither.

“So he stopped taking the medicine?” I presumed. “Did anything else happen?”

Continued
<-Previous 1|2|3|4 Next ->
Printer-Friendly Version