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A woman experiencing severe hypertension was admitted to an intensive care unit (lCU). Her doctor called in an order for
15 mg of hydralazine to be given intravenously every 2 hours. Because the doctor spoke with an accent, the nurse misunderstood him. She thought he said 50 mg.
After obtaining three 20-mg vials of hydralazine, the nurse drew up the contents of two of them and half of the third, then administered the drug. Within a few minutes, the patient's blood pressure dropped to 70/30 mm Hg and she became tachycardic.
Her doctor was summoned to the lCU. As soon as he saw the empty vials of hydralazine near the patient's bed, he realized she'd been given an overdose. A rapid infusion of I.V. fluids raised her blood pressure to a safe level.
Telephone orders can be misunderstood for many reasons. But taking certain precautions can resolve any misunderstandings before a drug is given.
First, always repeat the order back to the doctor, pronouncing each digit of the dose. For example, "That's 50 milligrams, fivezero milligrams, of Vistaril?" Or "You want 17 units, one-seven units, of regular insulin?"
Second, remember that a single dose of a drug will rarely amount to more than two dose units, whether they be vials, ampules, tablets, or capsules. If you've obtained more than two units for a single dose, double-check the order with the doctor. There's a good chance someone's made an error.