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William Tompkins and Rebecca Tompkins, unrelated patients, were assigned to the same nursing unit. Both were receiving I.V. antibiotics for systemic infections. Rebecca had a history of penicillin sensitivity.
One evening, Rebecca's nurse took a piggyback of Timentin from the unit refrigerator. This antibiotic contains ticarcillin disodium and clavulanate potassium. It had been intended for William. Soon after the infusion began, Rebecca broke out in a rash on her arms and trunk. Her nurse stopped the infusion and administered an antihistamine as ordered.
The pharmacist who'd prepared the bag of Timentin had labeled it with the patient's last name and first initial only. And the nurse had just looked at the last name. In Rebecca's room, she thought she'd properly identifIed the patient, so she didn't realize her error.
Unfortunately, mix-ups like this aren't uncommon. The easiest solution is to put two unrelated patients with the same surname on different nursing units. If this is impossible, unit secretaries, pharmacists, and nurses who transcribe orders and dispense or administer medications should always use the patient's first and last names in all written and verbal references.
You could also consider the "name alert" fluorescent stickers sold by some companies. These can be placed strategically on charts, I.V. labels, and so on to make everyone aware that two patients on the same unit have the same last name.