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1例78岁女性患者因高血压[196/93 mmHg（1 mmHg=0.133 kPa）]予乌拉地尔注射液100 mg入0.9%氯化钠注射液250 ml缓慢静脉滴注以降压，控制滴速为40滴/min，滴注过程中若血压降至目标值时暂时停药。静脉滴注乌拉地尔注射液40 min、输入药液约80 ml时，患者血压降至152/70 mmHg，暂时停药。交班护士未对接班护士介绍患者病情和乌拉地尔使用情况，接班护士也未核对医嘱，误将剩余的170 ml乌拉地尔在60 min内（60滴/min）滴注完毕。5 min后，患者出现头晕、乏力并剧烈呕吐等低血压反应，血压降至136/66 mmHg。立即给予补液治疗，约2 h后患者血压升至158/76 mmHg，不适症状缓解。“,”A 78-year-old female patient with hypertension (196/93 mmHg) received a slow IV infusion of urapidil injection 100 mg diluted into 250 ml of 0.9% sodium chloride injection to reduce blood pressure. The infusion rate was controlled at 40 drops/min. If the blood pressure dropped to the target value, the drug would be stopped temporarily. The blood pressure dropped to 152/70 mmHg when urapidil injection was intravenously infused for 40 min (about 80 ml). Then the drug was stopped temporarily. The nurse on duty did not introduce the patient′s condition and the use of urapidil to the nurse who would take turn on duty. The successive nurse did not check the doctor′s order and mistakenly infused the remained urapidil 170 ml within 60 min (60 drops/min). Five minutes later, the patient developed dizziness, fatigue, and severe vomiting, and the blood pressure dropped to 136/66 mmHg. Rehydration treatment was given immediately. About 2 hours later, the patient′s blood pressure increased to 158/76 mmHg and the symptoms were relieved.