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After a unit -dose cart supply was checked and delivered to the patient care area by a pharmacist, he received a new order for ampicillin 500 mg P.O. q6h. The pharmacist took three doses, enough to last until the next cart fill, and placed them in a Ziploc bag. He wrote the name of the patient and bed number on the bag and sent it to the nursing unit for the nurse to place in the patient's drug bin on the cart. The pharmacist did not notice that, earlier in the day, someone else had dispensed those very capsules and had written a name and bed number directly on the label of one of them. When the medication was later discontinued, the capsules were returned to stock but the name and bed number were not crossed off.
Upon receipt, a nurse removed one dose from the bag, then administered it to the wrong patient-the same patient for whom it had already been ordered and discontinued. Later, when the nurse saw the name and bed number written on the Ziploc bag, she discovered that an error had been made. She wrongly assumed that the name and the bed number written on the unitdose package label identified the patient for whom it was intended (she remembered seeing an earlier order for that patient, but was unaware it had been discontinued). Of course, if the nurse had followed procedure by checking the patient's medication administration record, the error would not have occurred, but the name and bed number on the label contributed to the error. There is a danger that similar errors could occur with stat doses and other miscellaneous, one-time-only items, as well as with drugs dispensed to update unit-dose carts before the next fill.
One of the major cost-saving advantages of unit-dose packaging is that dispensed but unadministered medications may be returned to stock for reissue without fear of loss of identity or hygienic conditions. But writing the patient name and bed number directly on the label of nonroutinely dispensed doses may later lead to error if the dose is returned. This practice should be discouraged. A supplemental label that can be torn off if the drug is returned would be more acceptable. Alternatively, all doses delivered after normal cart fill should go directly into patient bins or should be placed in Ziploc bags, which are then labeled. If returned, the doses may be removed and returned to stock.