, is a potential trap for the unwary health professional. Here's how one nurse misinterpreted it:| Contents | Previous | Next |
The U.S. Drug Enforcement Administration uses the symbols I, II, III, IV, and V to denote five classes of potentially dangerous drugs. In the United States, you'll see the symbol for any classified drug on its product label. But the class IV symbol, written
, is a potential trap for the unwary health professional. Here's how one nurse misinterpreted it:
A nurse who had been out of practice for nearly 20 years returned to work on a medical/surgical unit. This nurse received and transcribed an order for 10 mg of diazepam (Valium), to be given I.V. When she saw
on the box of diazepam tablets, she thought this signified hypodermic tablets that could be dissolved and given intravenously (hypodermic tablets were used 20 years ago). Then she compounded this error with poor sterile technique. She crushed a tablet in a mortar, added sterile water, drew up the dose in a syringe, and injected the solution into a patient.
When the error was discovered, the nurse explained she often prepared injectables from hypodermic tablets on her last job.
Another controlled drug that has been given intravenously instead of by its intended oral route is paraldehyde. Also, promethazine with Codeine
, a class V substance, has been confused with promethazine VC.
To avoid this medication error, all new employees, whether graduates or experienced nurses, should be instructed to recognize this potentially misleading symbol