| Contents | Previous | Next |
A nursing supervisor making rounds at a convalescent center entered the area for confused patients. She noticed a tube of nitroglycerin ointment on top of a unit-dose cart. No nurse was in sight.
She waited for the medication nurse to return, then reminded her that all medications must be kept inside the cart when it was unattended. The nurse promised she would lock up the ointment as soon as she finished using it.
Later that morning, the medication nurse called her supervisor and said, "I learned my lesson! I've looked everywhere for that ointment. Now tell me where you hid it." Unfortunately, the supervisor hadn't hidden it. .. and she had no idea where it was.
The staff quickly searched each room and finally found the ointment with an elderly patient. She said she'd taken the "skin cream" to soothe the dry skin on her legs. The nurses quickly wiped off the ointment.
The nitroglycerin ointment could have severely lowered her blood pressure possibly causing her to fall. Even a small amount can cause dizziness and severe headaches.
Preventing this kind of error is easy: Never leave medications within patient reach when you're not there. As soon as you've finished using a drug, lock it up.