Error Number 90. Being careless when stocking drugs

After giving birth, a patient on the labor and delivery unit began to bleed heavily. The doctor ordered a stat dose of Ergotrate (ergonovine maleate) to stop the bleeding.

The nurse went to the unit's stock of emergency drugs and took an ampule from the bin that was labeled Ergotate. As she broke open the ampule, she read its label and was surprised to see it said epinephrine. She quickly discarded the ampule and obtained another one from the same bin, confirming first that it was labeled Ergotrate. She administered the correct drug, and the patient eventually stopped bleeding.

This kind of close call can happen on any unit. Many emergency drugs appear similar because they're packaged in ampules; furthermore, the ampule labels can be difficult to read. If the pharmacist accidentally sends two types of drugs in one bag and the nurse stocking them doesn't realize it, she could easily put both drugs into one bin.

There are several ways to prevent this type of error:

• When stocking ampules, read each one's label, even though the bag containing the ampules is labeled with one drug name. By the same token, read an ampule's label when you obtain it for administration, even though its bin is also labeled.
• Remind all nurses on the unit that ampules are easily rmisstocked. Place a note in each drug bin reminding co-workers to read the ampule labels.
• Talk to the hospital pharmacist about getting drugs in containers other than ampules. Single-dose vials, prefilled syringes, and premixed solutions are some alternatives