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A doctor ordered a stat dose of I.V. glucagon, 1mg, for a diabetic patient who was having a hypoglycemic reaction. The nurse was to give a second 1-mg dose in 20 minutes if he didn't respond. The order was given at change of shift, so two nurses administered the doses.
The pharmacist had dispensed two boxes of glucagon, each containing a 1-mg vial of lyophilized glucagon powder for injection and a 1-ml vial of diluent. The next day, when he was preparing the unit-dose cassettes, he noticed that the patient's drawer still contained one vial of the powder. Because the diluent was gone, he suspected that one of the nurses had mistakenly administered just the diluent.
He was right. Although the vials were clearly labeled "Vial 1 (diluent for glucagon injection)" and "Vial 2 (glucagon for injection)," the nurse who prepared and administered one of the doses apparently hadn't read the labels carefully. She hadn't mixed the contents of the vials.
Of course, if she'd read the labels, she would have avoided this error. But the pharmacist could have helped out by putting a second label on each vial or on the carton containing the vials, reminding the nurse to mix the contents. Or he even could have mixed them himself before dispensing the drug.