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A patient arrived at the clinic to get her weekly allergy injections. After waiting a few minutes, she complained to the nurse, "I always have to wait. Can't you hurry it up for once?"
Annoyed, the nurse grabbed a vial from the refrigerator, quickly checking the antigen's name on the label. She prepared the first injection and administered it. As she prepared the second, she glanced at the vial again and was dismayed to see another patient's name on the label. She'd given the wrong antigen.
The nurse quickly told the doctor what she'd done. By that time, the patient had begun to have trouble breathing. She was taken to a hospital emergency department for treatment, where, fortunately, she recovered from the allergic reaction.
This error could have been prevented if the nurse hadn't let the patient rush her, making her neglect to check the vial's label against the patient's chart. Because the nurse saw this patient every week, she thought she knew which antigen was hers.
The lesson: Always check a drug's label against the order, regardless of how well you think you know the patient or the drugs she's to get. Take time to administer medications safely.