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A patient with an acetaminophen overdose was admitted to an emergency department and therapy began with the antidote, acety1cysteine. She was then transferred to a special care unit where therapy was continued. The doctor's original order read:
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Because the nurse was familiar with the use of Mucomyst as a mucolytic, she questioned the oral use of the drug and the dose. She tried unsuccessfully to get further information on this from her supervisor, two other nurses, and a doctor. The package insert mentioned only its mucolytic activity. Finally, after considerable delay, she changed the 3.5 g to 3.5 ml (3.5 g would be 17.5 ml) and administered it orally.
The incident occurred on a Sunday night. On Monday morning, pharmacy dispensed the balance of the order, properly labeled as 3.5 g = 17.5 ml. However, four days later, a pharmacist noted that the majority of the Mucomyst dispensed was being returned. After floor personnel were questioned, the original error was discovered and it was determined that the patient had not received the proper dose at any time during the four-day period. Fortunately, the patient survived the error. The error could have been prevented if one of the nurses had contacted the pharmacist on call or if a pharmacist had been on duty at the time the drug was ordered.