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A hemodialysis nurse discovered that the unit had exhausted its stock of 50-ml vials of mannitol 25% injection. (According to the unit's protocol, nurses administered mannitol to increase blood volume when a dialysis patient became hypotensive.) The nurse checked the backup supply and took a vial from the shelf where the mannitol was usually stored. Then she drew up the contents of the vial and injected the drug into a hypotensive patient. Almost instantly, he went into cardiac arrest. The nurse started cardiopulmonary resuscitation, but the patient died.
After the patient's death, nurses on the unit realized that he'd received mannitol from the backup supply, so they checked the discarded vial. It had contained lidocaine (lignocaine, Xylocaine), not mannitol. Both drugs were in 50-ml vials sealed with light-blue caps. After she removed the vial from the shelf, the nurse failed to read the label. She'd simply chosen the vial for its size, shape, and position on the shelf.
We all know the hazards of failing to read labels, but sooner or later someone will make this type of mistake. And, as in this case, a tragedy sometimes occurs.
But we can minimize the risk of error if we're on the lookout for potential hazards-and if we suggest ways to correct them. For example, a hemodialysis unit stocks Xylocaine to use as an anesthetic. But why in 50-ml vials? Smaller ampules or vials-say, 5 ml or 10 ml-would work just as well. If such a policy had been in effect, the nurse wouldn't have relied on the vial's appearance. Even if she had, the dose in a smaller vial would have been less likely to cause cardiac arrest.