A nurse preparing to administer a dose of the anti-infective drug metronidazole scanned a bar code at the top of the I.V. minibag label, and the scanner screen read levothyroxine, a thyroid hormone. She then scanned the bottom bar code, which is used for billing, and the scanner screen indicated metronidazole.
|Figure. No caption available.|
When the nurse carefully inspected the top bar code, part of the label had apparently been ripped as if it had been removed and reapplied unevenly. This created a new bar code that happened to read as levothyroxine.
If a label is ripped, pharmacy should print a new one. If you get a bar-code label that isn't intact, return the drug to pharmacy.