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A nurse noticed that a postpartum patient with a relatively minor infection was scheduled to receive an unusually high dose of penicillin:
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Thinking that another nurse had transcribed the order incorrectly, she looked at the original on the patient's chart and discovered a dangerous misinterpretation. The doctor's sloppy handwriting made the "G" after penicillin look like a 6. And he had written the 500,000 units as ".5 million units," instead of "0.5 million units." So the order did look like 6.5 million units.
The nurse called the doctor, who confirmed that he really wanted his patient to have only 500,000 units every 4 hours-a total of 3,000,000 units a day.
The doctor and the nurse who transcribed the order share the blame for this error. The doctor should have been more careful when he wrote the order. If he had put a zero in front of the decimal point and used the drug's proper name, penicillin G potassium, the order would have been clear.
The first nurse, though, should have realized that the apparent dose was much too high. Although it occasionally causes a serious allergic reaction, penicillin G is a very safe drug. But because each million units contains 1.7 mEq of potassium, a mistake in the administration rate or the dose could be fatal for a child or for an adult with a serious illness.