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A doctor telephoned the nurses' station and ordered 20 mg of hydralazine, intramuscularly, stat for a patient who had acutely elevated blood pressure. The nurse who answered the phone quickly jotted the order on a scratch pad.
While transcribing it to the doctor's order sheet, she was interrupted by another nurse, who asked, "Is the standard nitroprusside concentration 50 mg in 250 ml?" The nurse transcribing the order answered, "Yes, 50," and proceeded to write 50 mg instead of 20 mg on the hydralazine order.
The order was carried out by a third nurse, who obtained the hydralazine from floor stock and administered it to the patient. A short time later, a pharmacist reviewed a copy of the order. He immediately called the nurse who transcribed the order to tell her 50 mg seemed too high a dose. As he spoke, the nurse remembered that the dose should have been 20 mg and went to check on the patient.
The patient's systolic blood pressure had dropped to 90 mm Hg. The nurse alerted the doctor and continued checking vital signs every 15 minutes for several hours. The patient recovered without incident.
Interruptions are one of the leading causes of error. They're also a fact of life on most nursing units. Don't interrupt when you see someone else transcribing orders.