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An elderly woman with asthma was being hydrated with I.V. D5 W. The flow rate was set at 125 ml/hour. She was also receiving a piggyback infusion of 800 mg of theophylline in 500 ml, set to flow at 25 ml/hour. When her doctor checked on her, he decided to increase the flow rate of the D5W. He wrote on the chart:
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The patient's nurse saw the order and increased the flow rate.
About 90 minutes later, the pharmacist received a request for a second container of theophylline. Puzzled, because the theophylline should have lasted 20 hours, the pharmacist called the nurse and asked what had happened to the first container. When the nurse said it was almost empty, the pharmacist replied that it should have lasted for several more hours. Suddenly, the nurse realized that the order to "increase I.V." meant the D5 W, not the theophylline.
The nurse stopped the theophylline infusion at once and assessed the patient, who by this time had started to vomit. She called the doctor, who ordered a stat theophylline blood level measurement and an electrocardiogram. The results of these tests indicated theophylline toxicity. The patient was given supportive treatment and recovered, but the error could have been fatal.
This error could have been prevented if the doctor had specified which infusion rate to increase. But the nurse shouldn't have implemented the order until she clarified what the doctor wanted.
Don't make the same mistake: When you receive an order to change a flow rate and more than one solution is infusing, clarify the order before adjusting the rate.