A 29-year-old man with "brittle diabetes" was admitted to the surgery service for incision and drainage of a leg wound. The patient's medical history included chronic renal failure, hypertension, and prior stroke after a hypoglycemia event. Prior to surgery while still on the hospital floor, the patient's blood glucose level fell precipitously after receiving insulin, requiring glucose several times. Due to workload, the nurse did not accompany the patient during transport to the operating room (OR). Instead, the nurse informed the transportation assistant about the patient's extreme sensitivity to insulin.
The transportation assistant neglected to pass this information on to the surgical nurse or the anesthesiologist. The electronic health record (EHR) did not reflect the glucose levels because the bedside glucose-monitoring device was not docked, so the information did not upload to the EHR for physician or nurse review. The patient spent 90 minutes in surgery and went to the recovery room where the blood sugar level was found to be 15 mg/dL, confirmed on repeat testing. Fortunately, the patient recovered quickly once he received intravenous glucose.
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