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A severely burned patient had a continuing order for 50 mg of diphenhydramine HCl (Benadryl) to relieve itching. After several weeks of administering this drug, most of the unit nurses were familiar with it.
But one day, when a nurse took the patient's unit dose of medication from his bin in the medication cart, she thought it looked different-more like dimenhydrinate (Dramamine) than diphenhydramine. The package label confirmed her suspicion: It was phenytoin.
The nurse checked the patient's chart to see if a new order had been written for the dimenhydrinate. Finding none, she notified the pharmacist of the discrepancy.
The pharmacist remembered refilling the order for diphenhydramine but was unaware that the wrong drug had been dispensed. When the nurse asked him if these two medications could have been mixed up in his supply, he realized what had happened.
These two drugs were stored side by side on the pharmacy shelf. The pharmacist realized that when he had dispensed the drug, he'd apparently read the shelf labels of the drugs too quickly. Because their names were so similar, he accidentally reached for the wrong one.
In this case, a nurse's thoroughness and persistence prevented a medication error. Many nurses, however, assume that whatever drug is in the patient's bin must be the right drug to give him--especially when they've become comfortable with the unitdose system. But pharmacist error can cause the system to break down. That's why you still must read the package label and compare it with the medication administration record before administering a drug from a medication cart bin. If something doesn't look right, check the original order. Then question the pharmacist.