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A patient's medication administration record read, "Percocet-5 every 3 to 4 hours as needed for pain." Twice, over the next 24 hours, a nurse administered five tablets each from a bottle marked "Percocet."
What the doctor had meant was one tablet per dose of a drug formerly called Percocet-5. Luckily, the patient was only oversedated; he didn't experience a more serious adverse reaction.
Percocet (oxycodone), an oral analgesic, was called Percocet-5 until a few years ago, when the manufacturer dropped the 5. Now the label reads "Percocet"-exactly what these nurses saw when they went into the unit's narcotics cabinet.
Some health professionals, like this doctor, still call the drug Percocet-5. If your hospital stocks Percocet, be on the lookout for confusion over the name. You might ask the pharmacist to place a second label on the box to alert nurses to the drug's former name