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An unstable diabetic patient was hospitalized for debridement of a foot ulcer. Treatment included an infusion of clindamycin, 300 mg, in 100 ml of 0.9% sodium chloride solution every 6 hours.
The pharmacist prepared the solution in a piggyback I.V. bag and typed up a label stating the patient's name, bed and room number, name and strength of added antibiotic, and name of diluent. He placed this label over the manufacturer's label for the diluent and sent the bag to the nurses' station.
The nurse checked the information on the pharmacy label. Seeing that it corresponded with the order, she hung the bag and began the infusion. A few minutes later, the patient called her back to look at the portion of the manufacturer's label that was visible beneath the pharmacy label. The manufacturer's label identified the diluent as 5% dextrose in water, not 0.9% sodium chloride solution as stated on the pharmacy label.
The nurse quickly stopped the infusion and checked a drop of the solution on a reagent strip. Sure enough, the solution contained dextrose. The nurse notified the pharmacist, who prepared a new solution using the proper diluent.
Luckily, this patient knew enough about his disease and treatment to check both labels and discover the error. The small amount of dextrose he received didn't harm him, but a larger amount could have seriously compromised his condition.
Of course, most patients aren't that knowledgeable. To protect them from error, ask the pharmacist to leave the manufacturer's label uncovered when he adds the pharmacy label. Then be sure to read both labels when hanging an I.V. solution container. '