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A patient suffering from acute asthma was receiving I.V. aminophylline. The doctor's order was for 375 mg per liter of fluid over 8 hours, three times daily.
After a few days, a nurse on the night shift noticed that the solution dispensed by the pharmacy was labeled 250 mg of aminophylline per liter. She double-checked the doctor's order; it still called for 375 mg. Assuming that the pharmacist had mistakenly put only 250 mg of aminophylline in the I.V. bag, the nurse decided to correct the dose by injecting an additional 125 mg. She then administered the solution.
Not wanting to wake the pharmacist in the middle of the night to tell him what she'd done, the nurse left a note in the pharmacy mailbox describing the error and her action. When the pharmacist received the note the next morning, he immediately called the nursing unit. He had made a mistake. But the mistake was in labeling, not in preparing the solution. He had put the correct amount (375 mg) of aminophylline in the I.V. bag ... but had incorrectly labeled it as 250 mg.
Because the nurse had added 125 mg to the bag, the patient actually received 500 mg of aminophylline. This one-time overdose didn't harm him, but if the error had been repeated, he might have developed theophylline toxicity.
The nurse, who was quite upset by the error, felt she had learned a valuable lesson: Never alter a pharmacy-prepared drug dose without first checking with the pharmacist. If he made an error, he should be questioned about it immediately, even in the middle of the night.
By the way, for the most part, hospitals today use a standard concentration of aminophylline or theophylline that avoids the unusual one ordered here.