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A nurse in an extended-care facility knew her patients well enough to know she could trust some of them to take their medications unsupervised. One night, she left a patient's evening medications on his bedside table when he was out of his room, because she knew he'd take them when he returned.
The nurse completed her medication rounds and began her charting. A little later, a nursing assistant appeared at the nurses' station with a patient from another floor.
"Mr. Jones decided to visit your floor," the nursing assistant explained, "and while he was here, he went into a patient's room and took the medications on the bedside table. We're trying to find out what they were."
The nurse realized immediately whose medications Mr. Jones had taken. She quickly called the doctor and reported the incident. The doctor ordered that Mr. Jones be closely monitored for the next 24 hours. Luckily, he suffered no ill effects from the drugs.
This medication error occurred because a nurse-with the best intentions-bent one of the rules of safe drug administration: Never leave drugs for a patient to take on his own-stay with him until you observe him take them.
Leaving medications for a patient to take later could lead to any number of problems. For instance, a patient may decide to skip a dose. The patient's roommate may take the drugs by mistake. Or even more frightening, a depressed patient may hoard sedatives or other drugs and later take them all at once in a suicide attempt.
To prevent such errors, don't leave medications for a patient to take later, unless the drugs are specifically ordered for selfadministration (e.g., nitroglycerin, antacids). Stay and observe the patient take his drugs. If he refuses a dose, make a note of it and take the drug with you. If it's a p.r.n. medication or bedtime sedative, return later and offer the drug again.