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A nurse was relieving the regular medication nurse on a tuberculosis ward. All went well until she asked a patient, "Are you Mr. Thomas?’’ ‘’Wright,’’ he answered.
Assuming the patient had given an affirmative reply, the nurse then gave Mr. Wright the medications intended for Mr. Thomas. She realized her error two patients later when she found the real Mr. Thomas. Fortunately, since both men were receiving the same medication and dosage, no harm was done. Mr. Wright, however, also received a dose of clorazepate dipotassium (Tranxene) intended for Mr. Thomas.
Misidentifying a patient is one of the most common causes of medication errors. And checking a patient's identification band is the only sure way to identify him, although it may seem to be a bother. Even when you think you know your patient by sight, a last-minute transfer from one room to another, a confused patient, or similar-sounding patient names could lead to misidentification.
So always check the patient's identification band before administering a medication-and if he doesn't have one, get him one before you continue your rounds.