MEDICATION ERRORS: Turning down the volume

October 2005 
Volume 35  Number 10
Pages 10 - 10
  PDF Version Available!


A hospital pharmacy prepared an infusion of the fibrinolytic agent alteplase (Activase), 30 mg/30 ml, in an empty 100 ml I.V. bag and applied a label stating “30 mg/30 ml to be infused over 1 hour.” The nurse administering the drug saw the manufacturer's “100 ml” designation on the bag and assumed that it contained 100 ml of solution. She set the infusion pump at 100 ml/hour instead of 30 ml/hour and the drug infused in about 20 minutes.

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