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Error Number 127. Confusing "magnesium sulfate" with "morphine sulfate"

A new graduate nurse was working in an emergency department (ED) when she received an order for "M.S. 5 mg." She stood in front of the medication cabinet for several minutes searching for a drug with the initials "M.S." She found magnesium sulfate, which she took to the doctor. When she showed him the vial, he told her she had the wrong medication; he wanted morphine sulfate.

Obviously, the nurse should have asked him what he wanted before she went to the medication cabinet. If you don't understand an abbreviation, admit it--don't be too intimidated or embarrassed to ask.

This problem brings up another point: Don't use an abbreviation unless it's on the hospital's approved list. Most of us would know that an ED doctor wanted morphine sulfate when he asked for "M.S.," but a new graduate or a float nurse might not. And that could result in a serious error.