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A 16-month-old girl was scheduled to receive 350 mg of cefazolin sodium (Ancef, Kefzol) every 8 hours to treat a pulmonary infection. To prepare the first dose, the nurse got a vial of cefazolin powder and a vial of diluent. She mixed the drug with
3.5 ml of diluent, then gave the 350-mg dose through the heparin lock.
The baby immediately went into cardiopulmonary arrest. The nurse called a code, and the baby was resuscitated.
After the baby was taken to intensive care, the nurse returned to the medication area. She picked up the used vial of diluent and was about to throw it out when she read the label. It said potassium chloride injection. Horrified, the nurse realized she had mistakenly used a vial of potassium chloride instead of the diluent she wanted, sodium chloride injection. The bolus of potassium chloride had caused the arrest.
This error could have been prevented if the nurse had read the diluent's label before preparing the injection. The rule you were taught in nursing school, to read a label three times (when obtaining a drug, when giving it, and when discarding the empty container), applies to diluents as well. Don't rely on appearance; in this case, for example, both sodium chloride and potassium are colorless and appear to have the same viscosity. Check the label: That's the only way to prevent such an error.