Error Number 102. Confusing the identity of two patients with the same last name

A standing order for temazepam had been written for "A. Lambert," a nursing home patient. One night a nursing assistant told the medication nurse that "Lambert" was asking for a sleeping pill. The nurse checked her list of patients for whom sleep medications had been ordered. Seeing an "A. Lambert" on the list, she went to Mrs. Lambert's room, checked her armband (which read "A. Lambert"), and administered the temazepam.

About 30 minutes later, the nursing assistant mentioned that Mr. Lambert was still asking for his sleeping pill. The medication nurse was quite surprised to learn there were two A. Lamberts on the unitAlice Lambert and her husband Alan. She had given the temazepam to the wrong Lambert.

The mix-up caused no harm, but it does illustrate the unusual ways that drug administration errors can occur. To protect your patients from such errors, adopt these guidelines:

• If two patients with the same last name are admitted to your unit, inform staff members of this fact during report, and make a note on the charts.
• Make sure all patients' armbands list both first and last names.
• Use both first and last names when referring to patients.
• Before giving any medication, check the patient's medication administration record, not just a list of patients receiving a particular type of medication.