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A patient on a cardiac care unit was receiving a continuous infusion of 50 mg of Nipride (sodium nitroprusside), diluted in
250 ml of D5 W, to improve cardiac output. As the infusion was running out, the doctor ordered 40 mg of Lasix (furosemide, frusemide), I.V. push. The nurse obtained a 40-mg vial of Lasix and a 50-mg vial of Nipride. She reconstituted the Nipride in the vial, then set it down next to the Lasix to get a new bag of D5 W from the supply closet.
When the nurse returned, the doctor asked her to give the bolus of Lasix immediately. She picked up the vial, withdrew the drug, and injected it into the patient's I.V. line.
Suddenly, the patient's blood pressure dropped. The nurse called the doctor, then took a closer look at the vial she'd just used. It was the vial of Nipride.
Fortunately, the patient's I.V. had infiltrated, so she didn't get the full bolus of Nipride. After a vasopressor was administered, her blood pressure rose to a safe level.
This potentially fatal error occurred because the two vials were similar in size and color and because the nurse neglected to read the label when she withdrew what she thought was Lasix. Remember, always read labels when administering medications. Don't rely on the container's appearance. To further reduce the chance of error, prepare and administer only one medication at a time.