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A nurse was administering medications to a patient when he looked at the label on the unit-dose package she was opening. The label read aspirin, 650 mg. He told the nurse, "My doctor said not to take aspirin while I'm on Coumadin."
Surprised, the nurse wondered why she hadn't seen an order for Coumadin (warfarin sodium) on the patient's medication administration record (MAR). She knew if she had, she'd have questioned giving aspirin with this anticoagulant because aspirin increases the risk of bleeding and has an ulcerogenic effect.
The nurse checked the patient's MAR again but saw no order for Coumadin. She then checked his chart and realized what had happened.
In the chart was a special drug administration record_listing drug orders written on a day-to-day basis. This record documented that Coumadin had been given daily for the past 5 days. But because this special record was kept with the chart rather than the MAR, the nurses who'd been giving aspirin to this patient for the past 5 days hadn't seen it. And the patient had been too ill during that time to notice what drugs he was being given.
The nurse alerted the doctor, who discontinued the aspirin. The patient's prothrombin time remained within a normal range.
This type of error could easily have been prevented. Special drug administration records, which are usually reserved for anticoagulants and cardiac medications that must be reordered daily, are useful because they provide extra space for recording monitoring variables such as pulses or laboratory test results. But when these special records are kept in the patient's chart, his MAR doesn't give a complete picture of his drug therapy. Therefore, if these records are used, they should be kept with the patient's MAR. When all medications are documented in one place, you can quickly check to see if any are incompatible.
If the hospital where you work has a system similar to the one that caused this error, try to get it changed so all medications are documented in the patient's MAR. And be sure to tell the patient what drugs you're giving him. (Note that the person who discovered the error was the patient himself.) He should be the final check in the hospital's system for preventing medication errors.