Last week’s column described an error in which the doctor’s office got the dose for an allergy shot wrong by a factor of ten.   

More errors – some almost comical -- surfaced every month.  In one, the medical assistant (MA, a front-line worker making on average $27K in Prescott) announced that my pulse was 85 when the meter said it was 58.  She vehemently insisted that I was wrong to object; upon retesting, the meter gave a reading of 59.

She also read aloud my weight on the scale, and then recorded an entirely different number in my chart; the next month, she said with approval, “You’ve lost weight!” when the scale had given exactly the same reading both months.

Some of the errors were more concerning. 

The Mayo Clinic, which provided the allergy serum, requires that the health care worker carefully record from which vial the serum for any given shot is drawn. When a new vial is opened, they also require that my usual point five ml dose be split into two doses of point two five ml each, given a few days apart, because new serum is more potent than old serum.  The MA had been given written and oral instructions on this point, so I was startled when she said, “There’s about half a dose left in this old vial; next time, we’ll use that, plus serum from the new vial, to get the point five ml dose.”

“We can’t mix serum from two different vials in the same shot,” I said.  “The dosing is different when a new vial is first opened.”  She argued with me at length, but I insisted that she throw out the old, nearly empty, vial.

At the next visit, the nurse practitioner (NP) rushed into the room and said, “Zero point five!  Zero point five!  We’ve got the dosing right this time!  I’ve given [the MA]  her instructions:  both shots are zero point five ml!”

“Well, one of them is,” I agreed.  “The other is half that, zero point two five, because we are starting a new vial.”

“Oh!” the NP said, “That’s right!”

One month, the MA suddenly and unexpectedly rubbed the injection sites vigorously after giving the shots.  Although common practice with other shots, experts say that this should never be done with allergy shots; it can make the reaction much worse without providing any benefit, and that’s exactly what happened.

And so it went.  While some shots went off without a hitch, it was not unusual for one visit to involve multiple errors, some of which degraded my care just a little, and some of which could have been more serious.

Next week’s column details another misstep and my options going forward.