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A patient's heparin lock needed to be flushed because it was obstructed with blood. His nurse went to the medication room, reached into a bin marked "Hep- flush kits," and withdrew what she thought were Tubexes of saline solution and heparin.
She returned to the patient's room and injected the saline solution. As she withdrew the needle, she noted that the label on the Tubex read, "dimenhydrinate injection" instead of "sodium chloride injection." She'd administered a 50-mg dose of the generic equivalent of Dramamine. After notifying the doctor immediately, she closely monitored the patient, who slept soundly that day but suffered no other ill effects from the dimenhydrinate.
You know that you should read labels at least three times: when taking a dose from a patient's bin or the drug storage area, when preparing or administering the dose, and when discarding a drug container or returning it to stock. That last step can't be overemphasized. If you return a look-alike drug to the wrong storage area, someone else may bypass the first label check and pick up the wrong drug, which is exactly what happened here.