The Tale of the Enema and the Trailing Zero Error

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Nursing, again not paid enough

LUBBOCK, TX – The Institute of Medicine in 1999 shocked the world when they reported that up to 100,00 persons die each year due to medical errors.  Medical practices were changed and procedures modified in order to increase the margin of safety and uphold the defacto medical motto of “First, do no harm.”

One of the recommendations was the eliminate the trailing zero.  The goal was to prevent transcriptions errs in written doctor’s orders.  Using this method, an order for morphine would be written as morphine 2 mg IV (instead of morphine 2.0 mg IV).  Sounds easy, right?

Dr. Michael Bradford, a fresh-faced young intern at Central Community Hospital, recently learned a valuable lesson regarding patient safety and the training zero.  It seems that Dr. Bradford, who is currently assigned to the facility’s internal medicine ward, was taking care of a young lady admitted to the hospital for an unidentified stomach ailment.

During morning rounds, the internal medicine team head, Dr. Sylvia Childs, determined that the prudent course of action would be to administer soap suds enema.  Dr. Bradford, the intern on the team, was responsible for preparing the written orders that guide the care of the ward staff.  Because a very precise individual, he wrote, “Administer soap suds 700.0 ml PR x 1 now.”  In his attempt to keep up with the morning lightning rounds, his handwriting was not as clear as it should have been. The decimal point was hidden in the loop of the hastily-written “trailing zero” and not noticed by the nursing staff.

What happened next, you might ask?  The unnamed young lady received, yep, you guessed it, a 7000 ml or 7 liter soap suds enema, and produced such a positive response to treatment never seen before.  The amount of excrement produced by this intervention will be talked about for some time.  In a strange twist of fate, the young lady’s unidentified stomach ailment was completely resolved after her dramatic defecation.  She was discharged several hours later after multiple showers, pain-free and happy.

As for our young intern, Dr. Bradford, he continues his studies at Central Community Hospital, but is now referred to by everything as “Code Brown.”


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