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A nurse in the intensive care unit was caring for a man recovering from a cerebrovascular accident. Because he'd developed cardiac complications, he was scheduled to receive 0.125 mg of digoxin through his central venous catheter.
The nurse obtained the digoxin and the heparin and saline solution cartridges needed to flush the catheter. The digoxin cartridge held 0.5 mg/2 ml, so she knew she'd have to discard 0.375 mg to get the prescribed dose. She couldn't find a syringe on the drug cart, so she decided to get one from the nurses' station and discard the excess drug in the patient's room.
The nurse went to the patient's bedside and flushed his catheter. After taking his apical pulse, she put what she thought was the digoxin cartridge in the syringe and began to discard the excess drug. Suddenly, she noticed that the label read saline-not digoxin. She picked up the empty cartridge she'd just used to flush the catheter. It was the digoxin cartridge.
The nurse quickly notified the doctor. The patient wasn't harmed by the digoxin overdose, but he did have to spend an extra day in intensive care for observation.
The best way to prevent such errors is by reading labels. A unit-dose system of drug administration will help since the exact drug dose you need will be prepackaged for you. If you work in an area of the hospital where this system isn't used, prepare syringes in the medication room or at the drug cart, not at the patient's beside. Reducing distractions will eliminate errors. And again, so will reading the label before administering a drug.