Today I Learn… I make a point of learning something new everyday. This is what I learn each day

1, Jun 24, 2010

Shattering the Myth of Trust, Taking Care of Ourselves (2)

Filed under: Medical Accident — admin @ 12:51 am

Another real life story also from this book, the famous case of chemo quadruple overdose. This time a patient died of a killing overdose of cyclophosphamide. 39-ear-old Betsy Lehman, a mother of two young children and a breast cancer patient, had an experimental treatment at supposedly prestigious Dana-Farber, one of the best in the country, part of the Harvard Medical School.

The experimental protocol required patients to receive a high dose of cyclophosphamide at one gram per day. The physician order writes like this, “cyclophosphamide 4 g/sq over four days,” that is, the patient is supposed to receive a total four gram per square meter, spreading out over four days. The infusion nurse, unfamiliar with treatment plan, interpreted the order as 4 g on each of the four days and thus gave the patient four grams per day for four days, totally 16 g., thoroughly killing all cancer cells together with the patient’s life in three weeks, leaving two young children motherless.

Now, even if patients have done due research on the safe dosage of the drug and known that the doctor has written the right drug and dosage, they still need to be extra cautious to make sure that the nurse correctly carries out the doctor’s order. The mistakes of a nurse can be fatal, as in Lehman’s case. Well, it is our lives and we just cannot trust anybody else to do the right thing. We have to learn to be smart patients.

P.S. my daughter commented, “Indeed, you cannot trust them all. They are humans, too and they make mistakes like all of us.” Indeed, the cost of their mistakes is too dear for any one of us.

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