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At the start of a code, a nurse undid the sterile wrapper on a D5W bag and added four 400 mg ampules of Intropin (dopamine hydrochloride). She put the bag on the crash cart next to the empty wrapper but didn't label the bag to show that the drug had been added. The I.V. was never started, though.
When the confusion of the code dissipated, another nurse saw the unused, unlabeled bag. Assuming it had just been taken from a nearby wrapper, she put it back into the wrapper and returned the package to the nurses' stock shelf.
About 20 minutes later, a third nurse entered the stockroom to pick up a D5 W bag for one of her patients. When she saw the opened package on the stock shelf, she assumed it'd been opened by mistake and contained a fresh bag. So she used it to start her patient's I.V.
Meanwhile, the first nurse was finishing her report on the code. Suddenly, she remembered the I.V. bag she'd mixed but hadn't hung. Fortunately, she located the bag before the third nurse's patient had received any of the solution.
In this instance, the patient escaped harm. But the consequences of this error could have been serious. So hang only I.V. bags you've unwrapped yourself-unless they were prepared and labeled in the pharmacy. And if you must add medication, be sure to label the bag immediately. For dopamine, you can completely avoid making infusion solutions if your hospital will purchase the premixed variety.