| Contents | Previous | Next |
While assisting a surgeon during eye surgery, a nurse prepared injections of gentamicin and balanced salt solution but didn't bother to label either one. Gentamicin is injected under the conjunctiva to prevent postoperative infection; balanced salt solution is sometimes injected directly into the eye to restore intraocular pressure.
Toward the end of the operation, the surgeon asked for the balanced salt solution. The nurse handed him one of the two syringes and he injected its contents into the patient's eye. As he did so, the nurse realized that she had given him the syringe containing the gentamicin.
The mistake was irrevocable-and tragic. The patient became blind in that eye.
This unfortunate incident occurred because of a mistake that's easily avoided-failing to label syringes. The nurse apparently thought she would remember which syringe was which.
In most cases, of course, the pharmacist will prepare and label injections. This is routine practice in many hospitals, as is the dispensing of commercially available prefilled syringes.
But when you must prepare an injection, don't make the mistake just described. Always label the syringe immediately. (The pharmacist can supply typed labels to make this step even easier.) Keep the vial with the syringe, and show the vial to the doctor when he's ready to administer the drug.