The nurse, a traveling nurse, was working on a unit and received orders to infuse saline into a 7-month-old infant. He saw a small bag containing what appeared to be saline on the desk in the infirmary, with the manufacturer's pre-printed label indicating that it was filled with normal saline. A key aspect, as described by the traveling nurse, was that in other health systems she had found that pediatric infusions were specified in small envelopes. Based on these two perceptions, the nurse administered the infusion, even though the label applied by the pharmacy was on the other side of the bag. Needless to say, the child died shortly after receiving the infusion, despite resuscitation attempts. The infusion was actually prepared for your adult patient