I added Aquadest on it, didn't I? Omygod! That's alcohol 70%!

[chadvena]

Did you use this?" she asked me. I shocked my head and said yes because I remember that was the one that I used. Furthermore, she whirled that bottle and I saw a little text written by marker, I swear it wasn't attract the eyes to take an attention, and it read "Alcohol 70%".

I want to share my bad experience. With this one, a lesson learned for me to be more careful and I hope it reminds you about little things that can be hazard for your patient.

First, I'm really sorry for my patient.

It happened about 2 years ago. I was on my clinical practice in a small hospital. As usual, our group divided into different team. I was with a friend, follow a nursing senior prepared the injection medicine for the patients.

I remember, that was Ranitidine. I asked for made it into 10 cc with Aquadest. My senior nursing was busy enough so I just did it without asked anything to her. Those were 2 Aquadest bottle, I recognized that was Aquadest just from the bottle. When the medicine done prepared, we gave it to the senior. Then we injected it to the patient via intravenous line. And then.....

"Aaaarrghh!!" the patient screamed out loud. She seems very painful when I gave that Ranitidine. My senior said, "Calm down, Mam, this medicine is little bit sharp but that's okay." Heard that, I continue and it was just 0,5 cc that in to the blood line. The patient cried out more and I didn't have the heart to continue.

My senior asked me to stop, then took the spuit, walked back to nursing station, I followed behind. She sprayed that medicine in her hand, then smelled it. She saw me with indescribable face, and went to medicine preparation room, then took one of the Aquadest bottle that I used to diluted that Ranitidine.

"Did you use this?" she asked me. I shocked my head and said yes because I remember that was the one that I used. Furthermore, she whirled that bottle and I saw a little text written by marker, I swear it wasn't attract the eyes to take an attention, and it read "Alcohol 70%".

Oh my God! Suddenly I felt faint. What did I do to my patient? Fortunately, the medicine didn't yet all given.

"Well I didn't know who is really responsible for this. But your mistake is you didn't careful, my mistake is I didn't lead you well, and the biggest mistake is owned by someone who used this bottle for alcohol and didn't write clearly and put it beside the real Aquadest."

Lesson learned everybody, don't ever use a secondhand bottle or another container for another liquids or contents. If it really needed to use, make sure you write it down very clearly to make all staffs know about it. Nursing isn't an individual work, it's required team work. So every single thing should be communicate clearly.

Fortunately, my patient was still healthy, and some hours after that accident she could be discharge and back at home. And so lucky me, I didn't get the punishment from the senior nursing there and instead it became a lesson for them.

Be watch out, Nurses! Our hands hold many lives!

[NanaPoo]

What is Aquadest? In 16 years of nursing I've never heard of it. And, if it's so dangerous to mix with meds why is it anywhere near your med cart?? And why on earth is someone using a wrongly labeled container for another liquid? This has sentinel event, lawsuit, and patient incident written all over it!

[klone, MSN, RN]

Why are people storing alcohol in an empty medicine vial? And if you're a student, shouldn't someone be observing you draw up meds?

[klone, MSN, RN]

What is Aquadest?

From what I can gather through google, it's German - vials of distilled water.

[NanaPoo]

But it's 70% alcohol??

Ohhh...I think I'm understanding. Someone put alcohol in the Aquadest bottle? Are there no laws regarding storage and labeling of chemicals in this workplace?

[BuckyBadgerRN, ASN, RN]

I can't think of one thing about this scenario that is reassuring!

[ProgressiveActivist, BSN, RN]

Chadvena is from Indonesia. She had a wise instructor. Thank you for sharing your story.

[Johnstonep]

Thank you for sharing your story. It underlines the importance of procedures put in place to prevent things like this from occurring. This never should have happened. I'm happy that your instructor followed the correct path, and that you were kind and brave enough to tell us the story. Thank goodness there was no lasting harm to the patient!

In the often chaotic world of nursing, we constantly need to be reminded of safety. Thanks again!

[calivianya, BSN, RN]

Good reminder!

I'm just glad we have single-use vials of saline and sterile water stocked in the carts in every patient's room. I can't imagine using water someone else has opened for med reconstitution, even if it was indeed what it says it was. That just doesn't seem sterile.

Question - how did the alcohol get in there? I'm assuming the bottle had a rubber stopper/diaphragm on it because I can't imagine it staying sterile any other way... but it's also hard to imagine someone drawing up alcohol in a syringe and injecting it into a vial through a stopper. It seems like the logical conclusion is that you can just open the bottle and pour something into it...

I honestly find that thought more horrifying than the labeling mistake. Not only multi-use IV fluid, but multi-use IV fluid in a bottle that can be opened to the air at any time? That's not sterile.

Please tell me I'm wrong.