A 72-year-old man was admitted to the hospital with community-acquired pneumonia and hyponatremia. During his third hospital night, the on-call physician was contacted by the charge nurse, who had received a "critical panic value" call for a potassium level of 2.2 (normal=3.5-5). The physician began writing for an EKG and immediate potassium supplementation. While writing the orders, he quickly glanced in the electronic health record to see what the patient's previous potassium levels were. To his surprise, he discovered that the patient didn't have a potassium level listed in the computer for that day; nor was there evidence that one had been ordered or drawn.
After calling the charge nurse back, they discovered the panic value was intended for a different patient with a similar last name on the unit. It was unclear if a "read-back" occurred between the lab tech and the charge nurse, who was covering for the patient's bedside nurse while the latter was on her break. Luckily, this was a "near miss"—the patient did not receive the unnecessary and potentially dangerous potassium supplementation and had an otherwise uneventful hospital course.
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