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A medication nurse, reviewing the medication administration record of a patient being treated for dysfunctional uterine bleeding, saw she was to give the patient an intramuscular injection of 125 mg of Delalutin (hydroxyprogesterone caproate). Since she was unfamiliar with the drug, she looked it up and verified that it was indicated for menstrual disorders.
When she looked in the patient's drug bin for the medication, however, she couldn't find it. Instead, she found a 250-mg ampule of Dilantin (phenytoin) injection. The nurse knew the patient didn't have a seizure disorder, and she knew of no other condition Dilantin would be indicated for.
She called the pharmacist and explained what she'd found. He then realized that he'd mistakenly read the order as Dilantin and dispensed the wrong drug. He immediately sent the proper dose of Delalutin to the unit and retrieved the Dilantin.
This nurse's diligence prevented a medication error. So be sure to follow her example in your own practice: Always check the patient's diagnosis, and look up drugs you're not familiar with before administering them. Don't give what's in a patient's drug bin just because it's there; compare the drugs with the order.