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A few minutes before afternoon report, the day medication nurse gave a patient 7.5 mg of warfarin (Coumadin), then charted what she'd done in the medication administration record (MAR). When the evening medication nurse asked the nurse giving report if the patient had received the drug, she said she didn't know.
After report, the evening medication nurse took a dose of Coumadin into the patient's room and asked him if he'd been given the drug. The patient said he'd received a new medication about an hour earlier, but he didn't know its name. The nurse left the Coumadin on the patient's bedside stand and went to check the MAR. She discovered that the patient had received the Coumadin, so she went to retrieve the drug from the patient's room. But the patient had already taken it.
What went wrong? First, the evening medication nurse shouldn't have tried to give the drug without checking the MAR before she went into the patient's room. Second, she shouldn't have left medication on the bedside stand. Finally, if the day medication nurse had educated the patient about his new drug, he could have told the other nurse what he'd take