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A doctor scheduled an outpatient for a barium enema and told the man to take 2 ounces (60 ml) of castor oil the evening before the procedure. The man's daughter, a nurse, bought the oil at a neighborhood pharmacy, then went right home and gave it to her father. The man, remembering how he'd hated castor oil as a child, swallowed the dose quickly.
Immediately, the man said he felt a burning sensation in his stomach. His daughter looked more closely at the bottle's label. To her horror, she saw that it was not castor oil but 20% camphorated oil, a rubbing compound that can be fatal if ingested.
The daughter rushed her father to an emergency department, where gastric lavage was performed. The man was closely observed throughout the night, and he recovered with no ill effects.
The next day, the man's daughter returned to the pharmacy where she had bought the oil to see how she had picked up the wrong bottle. She found that the castor oil was placed on a shelf directly above the camphorated oil. Both bottles were the same size, made of clear glass, with similar blue-striped labels. She told the pharmacist what had happened, and he agreed that the two products should be separated.
As you know, many drug labels look alike. To avoid confusing drugs as this nurse did, read labels carefully, regardless of whether you're taking a medication from a hospital supply room or from a neighborhood pharmacy or supermarket shelf.
To help prevent a similar error outside the hospital, take every opportunity to teach your patients, family, and friends the importance of reading a label carefully before taking a drug themselves or administering it to someone else.
Ironically, this nurse's father may have been the last person to accidentally ingest camphorated oil. After a 6-year campaign, a New Jersey community pharmacist convinced the Food and Drug Administration to withdraw camphorated oil (a product with little or no therapeutic value) from the market.