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M E D I C A T I O N
S A F E T Y
2. SMALL PROBLEM These containers of BSS solution (an eye
wash) have had epinephrine (a dilation agent) added, but it would be
easy to miss that fact, because the added labels are small and are
applied to the backs of the containers instead of the fronts.
Anyone holding the mixture should immediately see what was
added, along with the date and time it was added, and the initials of
who added it. (Unknowingly adding additional epinephrine could
cause excessive dilation, or excessive duration of dilation.)
The date and time are key, because when admixing occurs outside of
a laminar hood, as was the case here, it should be done no more than 1
hour from preparation to administration. Also, although the caps are
reapplied, standard foil-wrapped-type labels are recommended.
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