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A code was called for a patient who'd developed ventricular fibrillation. After the patient had been stabilized, the doctor decided to replace the lidocaine (lignocaine) infusion that was running with one containing procainamide. He asked the nurse to add 1 gram of the drug to 500 ml of D5W injection.
The nurse searched the crash cart and found a lO-ml vial of procainamide. When she read the label, she thought it indicated that the vial contained 100 mg of procainamide. She drew up the contents into a syringe and began looking for additional vials.
Just then, the doctor called for a 100-mg bolus of procain¬amide. The nurse handed him the syringe. As the doctor started to inject the drug, the nurse read the vial label again and realized what it really said: 100 mg per milliliter, not per vial. She stopped the doctor from completing the injection.
Such an error points up the importance of familiarizing yourself with the contents of the crash cart before a code is called. If you see a drug label that's confusing, alert the pharmacist. He may be able to replace it with one that's less confusing. He may also be able to supply only single-dose containers. If a multidose vial must be used, he can add a cautionary label.