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Hospital employees should always read labels carefully before they prepare dosages. But they should be especially careful when new labels appear on familiar products. In one case, a nurse misinterpreted a poorly written label and gave a patient 10 times the dose of chloramphenicol sodium succinate (Chloromycetin Sodium Succinate) that the doctor prescribed.
The error began with a new, redesigned label (from the manufacturer) on a vial of chloramphenicol. The old label had stated clearly that the vial contained 1 g of chloramphenicol. But then the new label was substituted-a label that didn't state the quantity of drug per vial. Instead, it stated that 1 ml of the reconstituted drug would contain 100 mg of chloramphenicol.
A nurse who needed 2 g of chloramphenicol glanced at the new label and thought the entire vial contained only 100 mg of chloramphenicol. So she reconstituted 20 1-g vials and injected the drug. The patient died 11 hours later.
Poor labeling on the vial cannot be blamed entirely for this medication error. How could someone responsible for administering drugs reconstitute and inject 20 vials of a drug without thinking that something was wrong? How could someone administer a drug without knowing anything about its side effects and toxicity ?.
Clearly, this should never have happened. Yet in 1975, it actually did. At least five patients were accidentally given ten times the intended dose of chloramphenicol, according to a letter in the Journal of the American Medical Association (October 13, 1975). As a result, the manufacturer redesigned the label, clarifying the contents. Still we occasionally receive similar reports involving other drugs.
So if, for any reason, you ever find yourself in a position of needing to administer any dosage of more than one or two units (capsules, tablets, vials, or ampules), check with another nurse or a pharmacist.