A patient comes in because she “doesn’t feel good” and because she gets these “waves” through her body and feels that her implanted defibrillator/pacemaker is malfunctioning and shocking her.
She’s been seen in her doctor’s office, in the cardiologist’s office where the defibrillator was interrogated and found to have discharged twice in the past week, and in the emergency department twice for the same symptoms. Each time her exam was normal and the labs were normal except for a minor elevation in her cardiac troponin that remained stable throughout the week. The cardiologist attributed the minor elevation to the discharge of the defibrillator. Since troponin can remain elevated up to two weeks and since serial troponin draws were stable, the cardiologist wasn’t concerned.
Back again for the same complaint. She showed up while I was busy with another patient and the nurse reflexively ordered another set of standard labs – CBC, metabolic panel, cardiac enzymes.
An hour or so later, I get a phone call. The secretary says that it’s the lab tech and they want to speak to me right away about a critical value.
“Dr. WhiteCoat, this is Sue in the lab. The potassium on Deborah Peel is greater than ten.”
“Whaaaat?”
“Deborah Peel’s potassium is greater than ten. Can you read that value back to me?”
I looked at Deborah Peel’s monitor. Paced rhythm of 60. Normal.
I had the nurse look at Deborah Peel in the room. Watching TV. Upset because she has now had to wait an hour and a half for me to try to decipher what “not feeling good” actually means.
The normal range for potassium is from 3.5 to 5.1 mEq/L in our lab. The highest potassium I’ve seen in a living patient is 7.6 mEq/L. That patient was on dialysis and was “just too busy” to go to the past few sessions, so came to the ED at the end of the week for emergency dialysis. Saw a potassium level of 8.1 on a patient that was brought in with a full arrest. But “greater than ten” is a new record!
About this time I’m thinking to myself that either I’m on my way to a case report published in the New England Journal of Medicine … or … the lab is screwing something up.
“Did you verify that?” I asked.
“Yes. There’s no hemolysis. Can you repeat the lab value back to me?”
This whole “repeat the labs back thing” is another JCAHO requirement with good intent that serves no purpose. Bugs the bejeebers out of me. Yeah, I understand English. No, I don’t have auditory dyslexia. I got it.
I messed with her a little.
Deborah Peel’s bicarb is greater than ten.
“No! Her potassium is greater than ten!”
“Her potassium! Are you kidding me!?!”
“No! Now can you read that back?” She was getting peturbed, so I relented.
[Sigh] “Potassium greater than ten. Please send someone to redraw patient. Can you repeat that back to me?”
[Click]
Spoiled sport.
But it doesn’t end there.
Miraculously, after about 30 minutes, we get a printout from the lab stating that the repeat potassium value was 4.2. Damn. There goes the New England Journal of Medicine. At least I don’t have to insert an emergency Quinton catheter.
Then we get a report of the entire metabolic panel. It stated that the original reported potassium was 4.2 — normal. Suddenly the panic value of >10 had disappeared.
I called the lab to request the original report with a value of >10 to be sent and then a corrected report with the normal value to be sent.
“The first value was run on a backup machine and I don’t have a printout of it, so I have to enter the printed value.”
“But I ordered a second potassium level and the patient will be charged for it. You entering a normal value makes it look like I ordered the level for nothing.”
“I’ll credit the patient’s account, then. Nothing more I can do. Sorry.”
Dealing with this separately with the administration.
It’s just scary that Happy Hospitalist and ER Stories both had similar experiences with funky lab values within the past couple of weeks.
I did notice that one woman on Yahoo Answers! was alive and typing with a potassium level of 28.2. Now that thar’s some potassium for ya.
It’s an epidemic, I tell you.
My one-year-old daughter is on dialysis (PD) and awaiting a transplant. She recently had to have minor surgery and was kept in the hospital for five days as we re-started dialysis. The day before we were slated to go home, she had a potassium reading of over 9. The lab “thought” it was a mistake, so the resident ordered a re-draw and a bedside EKG, stat. One look at my smiling child playing with her favorite stuffed animals could probably have confirmed that the reading was a mistake but she received her third, fourth, and fifth stick of the morning in order to get enough blood for the re-test and was all clear with a value under 4 when the EKG tech showed up five hours later for the test that had been cancelled for over three hours. Agreed that it is an epidemic, with some serious side-effects.
We’ve had this as well lately. Bad values, as well as urines taking like 3 hours. Wonder what’s going on.
There was a peds pt on PO supplementation – the dose was being increased and was actually MORE than the adult max. He felt “funny” – had a K of 8.something. Threw the kitchen sink (albuterol, insulin/D5, everything) at it and he had a repeat K of 9.something. Dialyzed emergently…fine now.
I hate being on call for my group when I get a call from the lab like that. Since we only do outpatient now, I know that a Chem panel is likely done routinely, not stat, especially on a Sat.
They were able to walk into the lab, so I would doubt that a value of 7 was real.
I then have to get the phone #, then try to call a patient that I don’t know and explain to them why they have to go back to the lab. I have to get together with the patient personally since the lab won’t take a phone order. I also have to make sure the PCP gets the result.
In more cases than not it is due to lab error.
Last friday I had a patient come in to the pharmacy after receiving doxorubicin therapy for osteosarcoma of the fibula. The oncologist had prescribed ondansetron, levofloxacin, and “potassium perchlorate 200mg QD”. I figured the doctor made a mistake for the Chloride salt (and the dose) and called the hospital. The Fellow on call (Dr. out on Friday night) didn’t know what the deal was, and was especially surprised when I told him that potassium perchlorate was an explosive used in fireworks. He ended up getting no potassium (level was 3.8) and an appointment for Monday to figure out what the oncologist wanted.
I’m usually the guy that’s the blog troll ready to stand up and fight for the lab, but I just read an issue with erstories as well, and wrote the same thing. the common demoninator in all of these issues was an electrolyte issue. frankly the most commonly used methodolgies for electrolytes are extremely unstable. They have to be calibrated once every few hours. We don’t have a lot of tools to determine when they’re getting bad so alot of it is gut instinct and monitoring anion gaps closely. We don’t have the benefit of looking at a patient (or having the knowledge to do so) and say he’s healthy, a K of >10 doesn’t make sense. Basically what I’m saying is that if there’s an issue, all we can do is repeat the same specimen on the same faulty analyzer. We’re stuck inbetween a rock and a hard place. If we call to have that recollected people are pissed, if we turn out crap and let you decide what to do with it, you’re pissed. Anyway, sorry about the mini post and just remember that even places like my major trauma center sometimes have shitty equipment. NEVER trust a crapped out LYTE. They’re extremely volitaile and a better methodolgy hasn’t been invented yet. I’d be willing to bet the majority of whacked out lab results that don’t make a ton of sense are electrolytes.
How many times as a floor nurse were we notified from the lab that a sample was substandard….we knew they had dropped it, broken it, screwed it up somehow…at least part of the time. If the lables were placed to obscure the fact that the sample was short, rarely received a call back.
Not saying the lab was overly clueless, but they never will admit that THEY screwed up a sample/test.
Liz, I admit mistakes get made but I can honestly say sample don’t get dropped or broken and there’s not much we can do to screw it up. Most analyzers are able to pierce a vacutainer cap so I never need to take the cap off to “spill” it. vacutainers are hard plastic, they don’t break. And there is never a situation where I add something to an entire tube of blood, regardless of the sample. Real errors are one thing, stupid ass conspiracy theories are something else. most tests can be done on as little as 200ul, the problem comes from trying to repeat testing that doesn’t seem to make sense to us. That’s probably the only time you’ll have anyone say a sample is short. BTW. a full vacutainer is only about a tablespoon of blood. I hate hearing that we did a finger stick on a 22 year old male because he looked anemic. CRAP!
Maybe you should ask the others, HH, and ER if they are using the same reagents(company and lot number)!! Either that or the techs should run that a second time before they call you in a panic…
Perhaps controls and calibration if more than one patient range is not WNL.
[...] Call Room reports a case in which the hospital laboratory made an error in measuring a patient's potassium level. The value was so high, the physician [...]