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A patient who was NPO following abdominal surgery was receiving dextrose 5% in water with 1/3 normal saline solution and 10 mEq of potassium chloride in each liter of I.V. fluid to run at 100 ml per hour. The doctor wrote an order reading:
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However, the nurse transcribing this vitamin order thought that the doctor intended for the infusion to be reduced to a liter of fluid over 24 hours. She wrote in the Kardex: I amp Berocca-C to 1,000 ml/day. The label on the I.V. stand bottle in use still read: run at 100 ml per hour. But the nurse starting the new infusion reduced the rate to 50 ml per hour as indicated in the Kardex.
This error could have been avoided if the nurse who transcribed the order or the nurse who changed the flow rate had stopped to consider that the new rate meant that the patient, who was NPO, and had no other source of fluids, would have his fluid intake cut in half-a drastic change. Realizing this should have alerted them to double-check the medication order.