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A doctor wrote the following order for an elderly, 95-pound (43-kg) patient who was unable to sleep:
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When the evening nurse went to get the drug from floor stock, she found only 500-mg capsules in the chloral hydrate drawer. Assuming this was the only strength available, the nurse signed out one capsule and administered it to the patient.
Later, the nurse began to wonder if chloral hydrate was available in different strengths. She checked a drug reference and, to her dismay, discovered that chloral hydrate was also available in 250mg capsules. The nurse called the doctor, who said he'd thought chloral hydrate was available in only 250-mg capsules-which was the amount he wanted this patient to have. He asked the nurse to monitor the patient's blood pressure and respirations throughout the night. Then he came to the unit and rewrote the order, specifying a dose of 250 mg.
Luckily, the one-time, 500-mg dose didn't harm the patient. But both doctor and nurse learned that medication orders must specify the exact dose. If you see an order for one tablet, capsule, or ampule of a drug, call the doctor and ask for the precise' dose. Never carry out any order that's incomplete.