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A nurse received a doctor's order for Noroxin, I tablet b.i.d. But she wound up scheduling levothyroxine instead of norfloxacin. What happened?
Since the nurse wasn't familiar with Noroxin, she consulted an old drug handbook kept on the nursing unit. She couldn't find Noroxin in the book, but she did find Noroxine. Discounting the small spelling difference, she listed levothyroxine on the medica¬tion administration record.
She sent a copy of the order to the pharmacy. The pharmacist sent Noroxin. That's when she realized her error.
A similarity in drug names, and a nurse's false assumption, contributed to this medication error. Because Noroxin is a fairly new drug, it wasn't listed in this old drug reference. Noroxine, on the other hand, has undergone a name change, but it's still listed in some older reference books. Who knows what similar error will happen in the future-besides having similar names, some drug's usual doses even overlap.
To avoid such errors in your hospital, replace all your old drug reference books with the newest editions. Unless it's an extreme emergency, always have the pharmacist review the original order before giving the first dose.