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March 2010, Volume 40 Number 3 , p 18 - 18


  • Michael R. Cohen ScD, MS, RPH


A patient was prescribed a continuous I.V. infusion of 125 mg of diltiazem, a calcium channel antagonist. Because the infusion rate for the solution wasn't included in the order, the pharmacist who entered the prescription in the computer used the abbreviation UD (ut dictum, or "as directed") from a drop-down list used to fill in the rate field.The nurse who saw the notation on the electronic medication administration record thought UD meant that the 125 mg infusion was a "unit dose" injection and administered the diltiazem at 125 mg/hour. The entire dose was infused over 1 hour. (It should have been infused at 5 mg/hour.) The nurse then requested and received another bag of diltiazem from the pharmacy. Neither the nurse nor pharmacy questioned why another bag was needed so soon. The nurse administered the entire second 125 mg bag of diltiazem over 1 hour. The patient later died from this massive overdose.At a meeting to review this medication error, the hospital staff found that most

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