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A patient was receiving intravenous antibiotics through a heparin lock every 6 hours. Every time a nurse administered an antibiotic dose, she had to follow standard procedure for flushing the lock and instilling 1 ml of 100 units/ml of heparin to maintain patency.
On the third day of this regimen, the evening nurse checked the unit-dose heparin Tubex cartridges in the patient's supply and was shocked to find they were all labeled heparin sodium injection; 5,000 units/ml. She realized that since one of these cartridges had been used earlier that day, the patient had received a heparin overdose.
The nurse notified the patient's doctor, who ordered a stat activated partial thromboplastin time study. The results were normal. The pharmacy was also notified and the heparin cartridges were exchanged for those of the correct strength.
Unit-dose Tubex cartridges and syringes go a long way in making drug administration safer and easier. But don't let their ease of use and similar appearance lure you into cutting corners. Always read the label before administering a drug: when obtaining it, when giving it, and when discarding the empty container.