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An emergency department nurse received an order for 0.3 mlof subcutaneous epinephrine to treat an asthmatic patient and went to the drug supply room to get it. Because storage space was limited there, several different medications, including ampules of epinephrine (Adrenalin), benztropine mesylate (Cogentin), and haloperidol (Haldol) were stored in the same drawer.
As the nurse reached for the epinephrine, an X-ray technician who was leaving for the day stopped by to say good night. The two talked while the nurse drew up the medication.
The nurse then went to the examining room where the patient was waiting and administered the injection. She returned to the supply room to discard the used medication ampule. But when she picked it up, she was shocked to see it was not epinephrine but benztropine, an anticholinergic.
The nurse quickly notified the doctor, who told her to administer the epinephrine anyway. As it turned out, the benztropine didn't harm the patient.
The nurse was quite shaken by the incident. She realized how easily she could be distracted-and how dangerous that could be when preparing medications.
Never let anyone or anything distract you when you're preparing a drug for administration. If someone needs to talk to you, ask him to wait until you've administered the drug. And be sure to practice what you learned in nursing school ... to check the drug label at least three times: (1) when you remove the drug from a supply drawer or medication cart, (2) before you administer it to the patient, and (3) before you discard its container.