printed on the label. Assuming that meant she could administer the drug intravenously, she began drawing up the dose into a syringe. Another nurse saw what she was doing and stopped her.| Contents | Previous | Next |
A doctor whose patient was going through alcohol withdrawal called in an order for 5 ml of paraldehyde. He wanted it to be given orally, but his order was incomplete-he didn't specify the administration route.
A nurse who was unfamiliar with the drug took a container of paraldehyde from the floor stock. She saw
printed on the label. Assuming that meant she could administer the drug intravenously, she began drawing up the dose into a syringe. Another nurse saw what she was doing and stopped her.
Paraldehyde is classified as a Schedule IV drug under the Controlled Substances Act. The "IV" in the symbol
on its containers stands for the Roman numeral four, not "intravenous."
Until recently, paraldehyde was available in sterile containers and could be given orally, rectally, or parenterally. For economic reasons, the manufacturer stopped making the sterile form. Some health professionals, unfamiliar with this change, may believe it still exists. But currently no injectable form is being manufactured.
Unless the U.S. Drug Enforcement Administration changes the symbol, an error like this will happen again. In fact, diazepam, phenobarbital, and chloral hydrate-also drugs in the
category-all have been erroneously administered I.V.