本文报告一婴儿室１６名正常新生儿因误服０．１％新洁尔灭和亚硝酸钠混合液引起的急性中毒，临床特点，诊断及在综合治疗无效时经静脉换血疗法所取得的满意效果。并强调医院内对有毒的药品，一定要加强管理，要有醒目的标签，以防中毒。 This article reports the acute poisoning, clinical features, diagnosis, and satisfactory results obtained from intravenous transfusion therapy in 16 normal infants in a single infantile room due to misuse of 0.1% benzalkonium chloride and sodium nitrite in combination. And stressed that the hospital for toxic drugs, we must strengthen management, there should be eye-catching labels to prevent poisoning.