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After delivering a healthy baby, a woman developed severe postpartum bleeding and was transferred from the obstetrics unit to the intensive care unit (lCU). Her doctor ordered several medications for her, including Parlodel (bromocriptine mesylate), 2.5 mg, b.i.d., which was to be given to prevent lactation.
The ICU didn't stock Parlodel, and because it was past 10 p.m., the pharmacy was closed. (Nowadays hospitals with 200 beds or more have 24-hour pharmacy service.) So an ICU nurse phoned the obstetrics unit and asked to have some Parlodel sent over so the dose could be given on time. An obstetrics nurse put four tablets into a medication cup, labeled the cup Parlode!, 2.5 mg, and took it to the ICU.
Believing the four tablets equaled 2.5 mg, the ICU nurse gave all four to the patient. Within minutes the patient developed severe nausea and vomiting, abdominal cramps, and dizziness. The nurse called her supervisor, who checked back over the sequence of events and discovered that each tablet of Parlodel was 2.5 mg, so the patient had actually received 10 mg-an overdose of 7.5 mg.
The patient was monitored closely for hypotension. She recovered after spending a very uncomfortable night.
Any time a system of checks and balances is violated, errors are more likely to occur. In this case, the system was violated when the pharmacist was bypassed, the drug was borrowed from a source not responsible for dispensing medications, and the medication cup was labeled ambiguously.
The error was compounded when the ICU nurse, who was used to the unit-dose system, assumed that the label described the cup's entire contents. She didn't look up Parlodel (a drug unfamiliar to most ICU nurses) in a drug reference or ask another nurse about its dosage range. Neither did she question giving more than two tablets for one dose, which is often a sign that the dose is not correct.
To avoid a similar series of errors, ensure that the hospital where you work has a backup system for obtaining medications when the pharmacy is closed. (You can help convince administration to institute this system by documenting the need for it.) For example, the pharmacist can set up a night supply closet stocked with unit-dose packages of commonly used drugs. If a drug is needed that's not in the emergency supply, a pharmacist should be called-to either suggest an alternative to the doctor or to come to the hospital to prepare it.
Until such a system is instituted, though, be extremely cautious if you must administer medications obtained from a source other than the pharmacy. Always look up unfamiliar drugs in a reference. Be sure to have someone else check the dose. And don't forget to double-check when you must give more than two units of the drug to complete a dose ... a common sign that something may be amiss.