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A nursing staff development director was asked to fill in as a staff nurse on the intensive care unit (ICU). Although she had worked in an ICU before taking the staff development position, the nurse felt a bit disoriented being back on the floor. So while the previous shift's charge nurse was giving report, the nurse glanced around the unit, checking the location of equipment and supplies.
After report, she assessed the condition of her assigned patient and looked briefly at his medication administration record (MAR). She read that he was receiving phenytoin for seizure control and was scheduled to receive what she thought was an intravenous dose of 60 mg of phenobarbital.
The nurse checked the patient's bin in the medication cart but didn't see any containers of phenobarbital. Assuming the pharmacist had forgotten to put the phenobarbital into the bin, the nurse signed out the correct dose from the unit's floor stock. She administered the drug as ordered and sat down to chart what she'd done.
When she looked at the MAR again, she was dismayed to read that the drug she was supposed to administer was pentobarbital, not phenobarbital. She immediately told the head nurse and the doctor what she'd done. They quickly checked the patient, then explained that because the two drugs have similar actions, he would not be adversely affected.
The nurse was still upset that she had misread the drug name. She also realized that if she'd listened more closely to the change-of-shift report, she'd 'have learned that her patient was being maintained in a pentobarbital coma-a measure used to control status epilepticus. The coma was to be maintained until the following morning.
Some basic guidelines can help you prevent similar errors: