When the Wrong Judgmental Call Is Made


In the case where the life of another individual depends upon sound judgment, the person making that decision is accountable for the out-come of the call made.

It is expected of those who are in positions to hold the lives of others in their hands, to make the right judgmental call to save a life or to prevent harm.  There are too many errors made by those who hold such positions due to poor judgment, or an uncaring attitude that results in loss of lives in the medical field of science and elsewhere.

The Wrong Call

This is a medical judgmental call that perhaps cost the life of a patient.
Her physician wrote a standing order:
Give Tylenol #3 every four hours.
This patient had been taking Tylenol #3 for several weeks as ordered.  She had become dependent upon this medication, and would ask for it prior to the time of which her doctor prescribed.

Case in Point

8:00 p.m.  Patient was given Tylenol #3 per doctor’s order.
10:00 p.m.  This patient is asking for another Tylenol #3. The medication is denied based on her doctor’s orders. The patient is angry. She states she is in too much pain to wait.
10:15 p.m.  I received a phone call from this patient’s daughter. She stated, her mother is being denied her medication. And that if she does not get it immediately, she will come to the facility and make sure that she does. The daughter was told this patient has been given Tylenol #3 at 8:00 p.m., according to her doctor’s orders. And that she will receive the Tylenol #3 at 12:00 a.m., per her doctor’s orders.
10:30 p.m.  I received a phone call from the patient’s doctor. He stated, the daughter of this patient has called him. And that she is very upset about her mother being in pain and needing her medication. I informed the doctor that Tylenol #3 was given to this patient at 8:00 p.m., according to his orders, to give every four hours. And that based on his orders, Tylenol #3 would be given at 12:00 a. m. He said, “Go ahead and give her the Tylenol #3 now. “ Per doctor’s order, Tylenol #3 was given at 10:50 p.m.

Three days later this patient became severely ill. Her diagnosis was said to be a poison found in her blood.  Following that diagnosis shortly thereafter, she expired due to what was called, cardiac failure.

About This Medication:  Acetaminophen and Codeine (Combined) Tylenol 3
Side Effects: addiction
Painkiller, Narcotic

As with any narcotic, if taken incorrectly, it can be harmful,

Written by Ellen J. Barrier

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