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While preparing to administer a tablet of Tylenol #3 (acetaminophen, 300 mg, with codeine, 30 mg), a medication nurse noticed the numeral 4 on the tablet. She checked the label on the pharmacy-prepared container and saw it was marked "Tylenol #3." Puzzled, she checked the rest of the tablets in the container-all were imprinted with a numeral 4.
The nurse immediately called the hospital pharmacist to alert him to the discrepancy. He checked his inventory and discovered he'd mistakenly filled all the Tylenol #3 containers with Tylenol #4 tablets (which contain 60 mg of codeine).
By making one last check, this nurse prevented dosage errors for many patients, not just her own. Of course, not all medications are numerically coded, so you can't always compare them with the container's label. But when you can compare, do so. That extra check just might prevent a medication error.