It is so easy for mistakes to creep in to health care, as a recent experience reminded me.
I get two allergy shots – initially twice a week, then tapered to once a month – using serum made for me by the Mayo Clinic. Each injection contained a little more serum than the last until I reached the maintenance dose. Over 3-5 years of treatment, my body will grow to tolerate the plant and animal allergens to which I am allergic and stop reacting so violently to them.
I was getting the injections in my primary care doctor’s office. When they stopped giving allergy shots, I switched to another practice. The first time I went there, the barrel of the syringe they prepared had less than half an inch of serum in it. I was used to seeing a nearly full syringe. I objected, and was assured that the volume was the same; the difference was probably that the previous office had used much narrower needles. I didn’t think so, but couldn’t speak knowledgably about different types of syringes.
After I objected several more times, the very sharp nurse practitioner (NP) decided to double check – and discovered, horrified, that the three people involved in verifying the dose had accidentally moved a decimal point. They were planning to give me only one-tenth the amount ordered. In fact, the syringe chosen wasn’t even big enough to hold the correct dose.
The error could have been repeated month after month as they simply copied what they had done the previous month. I could have invested thousands of dollars and hundreds of hours over several years – only to get no benefit.
The stage was set for the error because care was handed off from one office to another; the details of my care were unusual (the dose I get is many multiples of the largest dose they had previously seen); three people with different levels of expertise made assumptions about how much the others knew or understood; the least-skilled person confused two similar syringes with different capacities; the dose was prescribed in one unit of measure, but the syringes chosen were marked with a different unit of measure; I lacked the technical knowledge to counter their arguments; and the professionals who’d just met me assumed that they knew more than I did about my care.
If the NP hadn’t finally decided to check the dose, next I would have asked them to explain the unit of measure on the syringe and how it related to the unit of measure in which the dose was ordered.
The moral? If you think something is wrong, speak up! Keep asking questions until you are comfortable that the right treatment is being delivered.
