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While making rounds, a doctor ordered an infusion of 100 mg of morphine in 500 ml of D5 W for a cancer patient in severe pain. He also ordered an infusion of 25,000 units of heparin in5OO ml of D5W for a patient who had thrombophlebitis. Both infusions were to be started immediately.
The medication nurse, to save time, typed the two admixture labels first, then prepared the two solutions. She affixed the labels and handed the containers to' another nurse, who then started both infusions.
An hour later, a nurse assessing the patient with thrombophlebitis discovered that his respirations were depressed. She called his doctor. After pulmonary embolism was ruled out, the nurse told the doctor that the patient had been fine before the infusion was started.
The doctor, suspecting a problem with the infusion, discontinued it and went to see the medication nurse. When he told her what had happened, she explained how she'd prepared a morphine and a heparin admixture at the same time. Since she knew she'd prepared the solutions correctly, she concluded she must have interchanged the labels.
That meant the patient with thrombophlebitis had been given the morphine infusion intended for the cancer patient, and the cancer patient had been given the heparin solution. The doctor ordered the cancer patient's infusion discontinued. Fortunately, the drug mix-up was discovered before either patient was harmed. New solutions were prepared and begun for both.
If your pharmacy doesn't prepare your I.V. drugs for you, resist the temptation to prepare more than one I.V. simultaneously. Instead, prepare one solution, then write and affix its label before preparing the next. This will ensure that you've labeled it correctly. Finally, investigate the use of manufacturer's premixed containers of heparin 25,000 units/500 m1 and other drugs. These solutions are already premixed, well labeled, and reduce the chance of error.