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A nurse working the night shift read this medication order for a woman recovering from a cerebral vascular accident:
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The nurse prepared a Mycostatin (nystatin) vaginal tablet according to its package instructions and inserted it into the patient's vagina.
The following morning, the oncoming supervisor asked the nurse if she had given the patient her suppository vaginally. The nurse said yes, but sensing something was amiss asked, "Is anything wrong?"
The supervisor replied, "Well, the patient was supposed to dissolve the drug in her mouth. She has an oral yeast infection." The nurse immediately checked the patient's medication Kardex. Sure enough, next to the order were the letters P.O. and "dissolve in mouth."
The patient suffered no ill effects. from receiving the Mycostatin vaginally, although she missed out on a dose to treat her infection. So even when a drug's administration route seems obvious, check it against the medication Kardex anyway. You may prevent an error--and save yourself and your patient some embarrassment.