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Best Practices Newsletter
Medication Mix-Up: A Case Study
August 6, 2007 | by admin | Permalink
Kathy Quan, RN, BSN
It’s your third day this week with the same patient assignment. That’s somewhat unusual because patients don’t usually stay more than a couple of days on your floor. It’s nice because you’ve had a tough couple of weeks and could use an easier day. Not that these are especially easy patients, but you are familiar with their cases. They aren’t whiney and demanding. They are eager to get better and to be educated in their care. In one room you have two patients who are about the same age. They look similar too. One is May and the other is Mary. May has the bed by the window. You are trying to find a good way of telling them apart for yourself. Of course you have to check their ID band for anything official such as medications, etc., but just for idle conversation you’re aware that if they weren’t in bed you could have difficulty. They both were admitted with similar abdominal complaints and have had a series of tests. One has been diagnosed with Crohn’s disease and the other is still waiting for more definitive information. They are both ambulatory and have become fast friends in this setting. You stop and think about how easy it can be to confuse your patients. Good thing you have to double check identities!! You realize why this is so important. Even though you have gotten to "know" these two patients,you can still mix them up. A little while later you’re passing meds and another nurse needs something from your cart. No problem you have May’s meds in your left hand because she’s next to the window and Mary’s in your right hand because she’s next to the door.
When you enter the room, both women are sitting in chairs next to the window. They will both need water for their medications; you go to get them water instead of handing them the medication cups first. "Uh oh", you set down the medication cups and suddenly you are no longer certain who gets which medication! One has a new medication and the other has something for tomorrow’s test. Once again, you think to yourself, "Oh dear, who gets what?" And you realize the patients won’t be able to recognize them. You think, "What do I do now?" Not only that, you’re in a hurry because a doctor wants you to assist him in the next room. You’re almost positive which medication goes to whom, but you aren’t totally certain. And to make matters worse, the other nurse took your cart back down the hall. You’re afraid you might look stupid in front of the patients or make them lose confidence in your ability if you question yourself. On the other hand, you could possibly mix up the medications and have a lot of consequences. The doctoris impatient, and he’s known to get very angry if he has to wait.
The best choice is to tell the patients that you forgot something. State that you will be back with your medications in a few minutes. Help the doctor and then double check the medications and get them to the right patient. Now, if there is a time restriction such as 30 minutes prior to a meal, you’ll have to instruct the patient to wait an extra few minutes before eating.
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