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During a procedure, a physician verbally requested "40 of K". This request was interpreted as 40mg of Vitamin K through IV by a nurse. Meanwhile the physician actually meant 40mEq of potassium chloride. The patient required further medication treatment and monitoring.
Source: summary of medical news story as reported by US Pharmacist
About: Vitamin K accidentally administered instead of potassium chloride
Date: 15 November 2004
Source: US Pharmacist
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