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A new graduate nurse, preparing to administer medications, noticed that one of the doses on the cart was in the manufacturer's original container. She carefully checked the label against the medication order, then poured out the capsule-the last one in the container. The capsule looked different from any she'd seen, but she assumed it was all right since it came directly from the manufacturer's container. She administered the capsule, then ordered a new supply for the next dose.
When the new supply arrived from the pharmacy, she noticed the capsules were completely different from the one she'd administered. Puzzled, she asked the nurse manager about the discrepancy. When she explained that she'd administered the last capsule in a manufacturer's container, the head nurse realized what had happened. The new nurse had administered the capsule containing desiccant, a drying substance that prevents medications from picking up moisture.
Luckily for this patient, the capsule passed through his body without causing harm. Some patients have needed surgery to remove such capsules that wouldn't pass through their gastrointestinal tracts.
Most hospital pharmacists don't dispense medications in the manufacturer's original container. But if the pharmacist at your hospital does, ask him to remove desiccant capsules before sending the container to the unit. If the container's kept tightly closed, the medications probably won't pick up any moisture in the short time they're stored on the unit.
And before you administer the last capsule in a manufacturer's container, look at it closely. Most desiccant capsules bear the printed warning: DO NOT EAT. Check it with the pharmacist if it looks unusual and you're unsure. And if you're returning a manufacturer's container with only one capsule to the unit's drug supply, make sure that capsule isn't the desiccant capsule. You may prevent a potentially serious medication error.