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A nurse administered furosemide (frusemide, Lasix) 400 mg to a patient instead of 40 mg. The medication error resulted from the compounding of many smaller errors. The nurse that administered the medication had worked in a patient care area where the full unit-dose system was used. She was transferred to an area where the traditional dosage system was used. When she received an order for Lasix 40 mg, she found that the stock supply was depleted, so she called the pharmacy and ordered one dose of Lasix 40 mg. The pharmacist, to be helpful, sent her 10 tablets of Lasix, 40 mg per tablet, as a temporary supply. He put them all in a vial labeled, "Lasix 40 mg." The nurse, who was accustomed to the concept that one package equals one dose, administered the 10 tablets.
Insist that pharmacists label drugs as specifically as possible, particularly in hospitals that partially use the unit-dose system. When you have any doubt at all about a label, question it. This error would probably have been avoided if the pharmacist had labeled the drug properly, as shown: furosemide (Lasix) 40 mg per tablet 10 tablets.