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A nurse working in a busy outpatient clinic was preparing an I.V. dose of the antiemetic dexamethasone (Decadron) for a man receiving cancer chemotherapy. She took a multidose vial of Decadron from a storage bin and set it on the cluttered work table. After double-checking the label, she turned to get a syringe and needle, then picked up the vial and withdrew the dose. She gave the drug and the patient went home.
A short time later, the nurse noticed an unused vial of Decadron and a partially used vial of heparin on the work table. She realized at once what she'd done: She'd given the patient I.V. heparin instead of Decadron. Calculating quickly, she determined that she'd given him 25,000 units of heparin.
The nurse called the doctor, then the patient, who had to return to the clinic for a partial thromboplastin time (PTT). Although the patient's PTT was elevated, he didn't need treatment and was sent home with instructions to avoid taking aspirin and to report any signs of bleeding.
This incident could have been prevented if the heparin vial had been returned to the storage bin-either by the nurse who took it out or by the nurse preparing the Decadron. Keep drug areas free of clutter. Prepare one drug at a time, and dispose of used containers properly. And always read the label on a drug vial immediately before you draw the dose into the syringe