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Error Number 153. Leaving medications meant for one patient within the reach of another

A patient took warfarin 20 mg, oxtriphylline 100 mg, and chlordiazepoxide 10 mg that was meant far his roommate. Haw? When the medication nurse entered the room an her rounds, she found that the patient for whom the medications were intended was slipping out of bed. She hurriedly put the medicine on the closest clear surface-the nightstand of the other patient. Since he was accustomed to. finding his  own medications placed there, he took them while the nurse was busy.

Be aware that you might be interrupted when administering medications. Be ready to. put the medications in a safe place until you can return to. them. The best rule is: Never leave medications meant for one patient within the reach of another.