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A nurse administered 300 mg of allopurinol (Zyloprim) to Mr. Jones in room 205--or so she thought. Actually, Mr. Jones had been transferred out of room 205 and Mr. Smith moved
in ... without the nurse's knowledge. When questioned later, the nurse admitted she hadn't checked the patient's identification (ID) band because she'd given Mr. Jones his medication for several days and was sure she recognized him.
In a similar incident, a nurse gave Mrs. Paterson in room 815 the furosemide (frusemide, Lasix) and Robitussin intended for Mrs. Rossman-who was in the room's other bed. How did the nurse confuse the two patients?
Mrs. Rossman had just been admitted and wasn't in her assigned bed. Mrs. Paterson, who'd just been brought back to the room after undergoing a lab test, was mistakenly put in the wrong bed. She wasn't wearing her ID band because it had been removed during the test. So while the nurse thought she'd confirmed the patient's identity, she'd only confirmed the right bed.
In another case, a nurse approached the patient in bed A of room 711 and saw that he had no ID band. So she called out, "Mr. Stankowicz?" -the name on her medication order. The patient answered "yes," so she gave him the medications. Unfortunately, he was Mr. McCoy. Mr. Stankowicz was in the other bed.
Mr. McCoy probably had poor hearing or was heavily sedated, or possibly was suffering from organic brain syndrome. He may have thought he was helping the nurse by answering yes.
In another similar example, the nurse knew that one of the patients in room 252 was to have milk of magnesia. Since the patient in bed A didn't have an ID band, she asked him his last name. His answer, Williams, matched the name on her order, so she administered the milk of magnesia. Later, she discovered the order was for the patient in the other bed. His last name? Williams.
In all these cases where medication was given to the wrong patient, the error could have been avoided by confirming the patient's identity first. So always check the patient's ID band against your order sheet. If he's not wearing an ID band, ask the patient his name ... first and last. Then confirm it with another nurse. And before you continue your rounds, get the patient a new ID band.