1. Cohen, Michael R. RPH, MS, ScD

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A radiology nurse almost administered chloral hydrate syrup to a patient I.V. when she mistook the symbol C-IV for "intravenous." The Roman numeral IV refers to chloral hydrate's Drug Enforcement Administration class four controlled substance status. Also, the label doesn't state that the drug should be administered orally, but it does say "dilute before using," which could make nurses think that the drug should be given I.V. In this case, the dose cup of chloral hydrate was retrieved from an automated dispensing cabinet (ADC), and the ADC screen didn't give the route of administration. A second nurse performing an independent double check caught the error before the drug was administered to the patient.


Most radiology nurses don't use medication administration records, instead taking the prescriber's order to the medication preparation area and to the patient. The nurse in this case was relying on memory-not the prescriber's order-to prepare and administer the chloral hydrate.

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The C-IV symbol has been misinterpreted in the past. For example, one nurse administered an I.M. dose of phenobarbital by the I.V. route, and another crushed diazepam tablets, dissolved them, and administered the dose I.V.


Drug manufacturers are allowed to use Arabic numerals on labels, so using C-4 instead of C-IV to identify class four controlled substances would reduce the chance of administration errors.