Dr. William Reichert commented on a recent post of mine. I thought he told an interesting story and with his permission, I am featuring it here so more of you might see it.
He wrote
Some time ago, I was consulted on a patient because of excessive urination. The patent was putting out 4 or 5 five liters a day and nobody knew why. I checked out all the usual suspects, diabetic ketoacidosis, hyperglycemia, diabetes insipidus, etc. and all the medications listed on his chart. No diuretics. Finally, at my wit’s end, I entered the ICU room and noticed a number of med bags, some full, some empty hanging there on the IV pole. I checked each and discovered a bag labeled "dopamine” slowly dripping in.
I went to the nurse and asked how long the patient had been on dopamine. She said "Hes not on dopamine." I said, "Come with me" and showed her that he was in fact getting low dose dopamine, a drug that behaves like a diuretic.
Unbeknownst to those "taking care" of him, he had been on dopamine for no one knows how long. The next day I got a call from the head of nursing informing me that it was not nursings fault. Perhaps the IV team or the pharmacy was responsible. I agreed with her. I did not want to be accused of being mean to the nurses. Anyway, according to the computer printout and the nursing notes, he was NOT on dopamine. Maybe a relative sneaked in and hung the drug. No one was faulted. The problem resolved. No "root cause analysis” was undertaken. Why bother?
This reminded me of a polyuria story of my own. One weekend, I was covering for another surgeon and rounded on a postop patient whose urine output had been increasing over the last several days. The labs were OK, and he had no obvious reason for his 3500-4000 mL/day outputs. I looked at the intake and output records [this occurred back in the day when such things could easily be found at the bedside] and saw that he was getting more and more IV fluid every day. I called a resident and asked him what was going on. He told me they had been increasing the IV fluid rate every day to keep up with the losses in the urine.
Facepalm!
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He wrote
Some time ago, I was consulted on a patient because of excessive urination. The patent was putting out 4 or 5 five liters a day and nobody knew why. I checked out all the usual suspects, diabetic ketoacidosis, hyperglycemia, diabetes insipidus, etc. and all the medications listed on his chart. No diuretics. Finally, at my wit’s end, I entered the ICU room and noticed a number of med bags, some full, some empty hanging there on the IV pole. I checked each and discovered a bag labeled "dopamine” slowly dripping in.
I went to the nurse and asked how long the patient had been on dopamine. She said "Hes not on dopamine." I said, "Come with me" and showed her that he was in fact getting low dose dopamine, a drug that behaves like a diuretic.
Unbeknownst to those "taking care" of him, he had been on dopamine for no one knows how long. The next day I got a call from the head of nursing informing me that it was not nursings fault. Perhaps the IV team or the pharmacy was responsible. I agreed with her. I did not want to be accused of being mean to the nurses. Anyway, according to the computer printout and the nursing notes, he was NOT on dopamine. Maybe a relative sneaked in and hung the drug. No one was faulted. The problem resolved. No "root cause analysis” was undertaken. Why bother?
This reminded me of a polyuria story of my own. One weekend, I was covering for another surgeon and rounded on a postop patient whose urine output had been increasing over the last several days. The labs were OK, and he had no obvious reason for his 3500-4000 mL/day outputs. I looked at the intake and output records [this occurred back in the day when such things could easily be found at the bedside] and saw that he was getting more and more IV fluid every day. I called a resident and asked him what was going on. He told me they had been increasing the IV fluid rate every day to keep up with the losses in the urine.
Facepalm!
