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In a hospital emergency department (ED), a nurse needed to give 10,000 units of I.V. heparin to a patient who had just been diagnosed as having a pulmonary embolism. Normally, 5 ml vials of 1,000 units per ml were available in the ED. But this time, the nurse found a 5 ml vial that clearly listed" 10,000" on the label right below the drug name. She drew up the entire contents and injected it I.V. into her patient.
Moments later, while hanging a follow-up heparin infusion container, another nurse came by with the empty vial and asked if the entire contents were injected. It turned out that the vial actually contained 10,000 units per ml. The volume she injected meant that she actually gave 50,000 unitsl
Looking at the vial more carefully, the nurse could see in small letters the words "units/ml" just below the 10,000. The vial's total volume was listed elsewhere on the label.
Although the nurse was at least partially to blame for not reading the label more carefully, the fact is that not all drug labels are as clear as they should be. Unless a manufacturer is extremely careful, he can unwittingly mislead users through malpositioning of important label information or by misuse of enhancements like boldface type, shaded backgrounds, colors, and size of type used for text.
In this case, the patient's physician felt that immediate administration of protamine sulfate, a heparin antagonist, was warranted. The patient suffered no sequelae.
To prevent such potentially fatal drug injections, be aware that labels can be misleading. Therefore, don't hurry such an important function as carefully reading the label. But you also need to do more. If you find yourself in a position of having to prepare an injection, make it a policy that at least another nurse or a physician double-check your work. Consider having both sets of initials on the medication administration record.
Finally, as a professional, you also have a responsibility to make some people aware of what you believe to be a misleading label. Let your pharmacist know so he can consider purchasing a less error prone product. And be sure to •call the USP (they set labeling standards the FDA must follow) so they can in turn inform the manufacturer (1-800-638-6725).