Medication Error Discussion
Nurse Sally Jo was caring for 4 patients, one was in pain, one was ready to be discharged, one had several 0900 medications due, and one was sleeping with family at the bedside. Sally Jo went to the medication room to prepare the medications. She pulled the 0900 medications from the patient’s drawer, left them in their original containers with barcode information, and went to the automatic medication dispenser to obtain the pain medicine for her other patient. While she was there, she was interrupted several times with requests from other personnel and inadvertently took out the wrong patient’s pain medication. Following the policy of the unit, she identified the patient, barcoded the medications and appropriately gave the 0900 meds. However, when she followed the same steps with the pain medication, she found she had the wrong medication. She retraced her steps, returned the wrong medication and obtained the correct medication and administered it. Should she report it, after all, the wrong medication was not given?
