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An 8-year-old diabetic patient who had developed ketoacidosis was admitted to an emergency department. As one nurse drew blood for glucose levels and other laboratory tests, another nurse took an I.V. bag from a box labeled "sodium chloride injection" and started an I.V. infusion. She also administered insulin.
When the first nurse finished drawing blood, she looked up at the I.V. container and noticed that it was dextrose injection-the last thing a diabetic patient in ketoacidosis needs. The nurse immediately clamped the line, found the correct solution, and hung it. Luckily, only a small amount of dextrose had been infused.
Don't rely on the labels on boxes to identify drugs or I.V. solutions. Someone may have put the drug or solution in the wrong box. (The same goes for labeled trays, drawers, or shelves.) The only reliable way to identify a drug or solution is by reading the immediate container label.