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A doctor ordered "Cardene, 30 mg P.O., q8h" for a patient who had a history of migraine headaches. Cardene is the trade name for nicardipine, a new calcium channel blocker similar to nifedipine (Procardia). The nurse misread this written order as "codeine." She got the dose from the unit's narcotics cabinet and gave it to her patient.
The next day, the doctor discovered the error on the patient's medication administration record. He told the nurse, who'd never heard of Cardene.
Pharmacists should alert nurses to new drugs and provide information to supplement any drug reference book on the unit. That hadn't happened at this hospital. So even if this nurse had wanted information about Cardene, she wouldn't have found anything about it in the drug book.
This patient had taken Cardene before, which she told the nurse later when questioned about her medications. That underscores the importance of getting a complete drug history as soon as possible after a patient is admitted.