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A 1-month-old premature infant weighing only about 5 pounds (2.2 kg) was hospitalized with an infection. Her doctor wrote the following orders for abdominal X-ray and abdominal girth measurement, as well as an order for ampicillin, 60 mg, to be given intravenously every 6 hours:
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Because the loop of the "q" in the line above the ampicillin order looked like a "0," the ward clerk misinterpreted the order as 600 mg, which is what she transcribed on the medication administration record. The infant received three doses of 600 mg of ampicillin before a nurse questioned the high dose the following day. Although the infant suffered no ill effects from the overdose, she probably would have eventually.
Preventing this type of error involves more than writing orders clearly. Here, a pharmacist and three nurses, including the one who checked the transcription, had failed to question a daily dose of 2,400 mg of ampicillin for a 5-pound infant.
The lesson is clear: Know the dosage ranges of drugs you commonly administer. And check transcriptions carefully to ensure they make sense. Such diligence may save a patient's life