Lack of standard dosing units and measurements creates mishaps in intravenous drug administration.

10 P&T® • January 2011 • Vol. 36 No. 1 sponse. The patient was then taken to a nearby hospital for admission to a criticalcare unit. When the transport team arrived, one of the paramedics reviewed the patient’s IV infusions and, per protocol, independently calculated the rate of infusion for each. While reviewing the pump settings, the paramedic noticed that the dopamine dose had been programmed in mcg/kg/hour, not in mcg/kg/minute. Although a Baxter Colleague smart pump had been used to program the initial infusion, the nurse had elected to bypass the pump library and instead used the pump in the dose-calculator mode. Looking at the screen to choose dosing options, the nurse accidentally selected mcg/kg per hour, which appeared on an alphabetical list before mcg/kg per minute. This sequence represents a pump feature with the potential to result in an error because mcg/kg per minute is used more frequently than mcg/kg per hour. After the pump was reprogrammed to deliver the correct dose, the patient’s blood pressure increased and he became conscious. The patient was then transported to the nearby hospital and was discharged five days later.