Error Number 113. Confusing a vial of Demerol with a saline solution flush

A busy nurse was preparing to give an I.V. antibiotic to one of her patients. She obtained the premixed minibag and attached it to the patient's I.V. set.

At the same time, another nurse withdrew a Tubex of meperidine (Demerol), 100 mg, from the drug cart's narcotic drawer. Seeing that a dose of hydroxyzine (Vistaril) was supposed to be given at the same time, she set the Demerol on top of the cart while she went to get the other drug.

Meanwhile, the first nurse remembered that she needed to flush her patient's I.V. line before giving the antibiotic. She came out to the drug cart and, seeing the Tubex lying on top of it, picked it up, thinking it was a saline flush. She then proceeded to inject the 100 mg of Demerol into the patient's heparin lock.

The patient immediately developed respiratory distress and had no audible blood pressure or palpable pulse. The nurse read the label and realized what she'd done. She called a code. The patient was given naloxone (Narcan) and was revived.

Two commonsense rules can help prevent such errors:

• Never leave any medication unattended .
• Always read the label on a medication before you give it; don't rely on its appearance. Make this rule second nature when administering drugs.