Seema, 16, was admitted to my unit with hemolytic uremic syndrome. I explained to her mother that I was concerned about hyperkalemia because of a drop in urine output and ECG changes and that I was waiting for a lab report to check her potassium level.
When I heard the printer humming, I rushed over to read the test results. Relieved to see "K+ 4.6," I quickly reassured Seema's mother that this level is normal.
Minutes later, however, a co-worker handed me another lab printout. The notation "K+ 6.1" appeared under Seema's name. In my haste, I hadn't realized that the first lab printout belonged to another patient. I immediately notified the health care provider, who ordered a sodium polystyrene sulfonate (Kayexalate) enema. I informed Seema's mother and administered the treatment.
Now I check the patient's name first on every printout I read and on every patient document I handle.
Copyright Springhouse Corporation Aug 2003
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