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A nurse took a pharmacy-prepared I.V. piggyback dose of cefazolin (Ancef), 1 gram, from the refrigerator. She checked the computer label, which included the patient's name, room number, and medication order. Then, she rechecked it against the patient's medication administration record. Before administering the antibiotic, she also verified the patient's identity. Everything appeared to be in order.
The next day the nurse's manager told her that an incident report had been filled out because the patient had received the wrong drug. The mistake had been discovered by the nurse on the next shift. She was about to give the patient another dose of the antibiotic when she realized that the pharmacist had erroneously placed the patient's label on a bag of ampicillin. The original label-the one the pharmacist had put on the bag when he had originally mixed the I.V. that morning-was visible.
You rely on the pharmacy to dispense drugs accurately, and a degree of trust is essential. But don't trust blindly. Check all labels on any container or I.V. bag.
Human error is always possible. Trust. .. but also verify.