July 2007, Volume 37 Number 7 , p 12 - 12 [FREE]


  • Michael R. Cohen RPH, MS, ScD


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Cohen, ...


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.

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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.