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A patient had an epidural catheter for intermittent morphine injections and a central line for I.V. fluids and other drugs. Neither catheter was labeled. Confusing the two lines, his nurse mistakenly injected 100 mg of furosemide (Lasix) into the epidural catheter. Fortunately, the patient wasn't harmed.
This error illustrates an all-too-common problem-the inadvertent injection of medication into the wrong tube. To prevent mixups like this, label all catheters at their distal ends. Also, trace each catheter from its insertion site to its most distal point, including the I.V. bag or bottle, before injecting a drug.
You can avoid potential errors by making sure that catheters-including nasogastric tubes, indwelling urinary catheters, and central lines-are in place only if absolutely necessary, or are disconnected as soon as possible.