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While a medication nurse was making rounds, she discovered that the trans dermal nitroglycerin pad she had applied to a patient's upper arm an hour earlier was missing. She asked the patient about it, and he replied that "another nurse removed the pad when she gave me my bath."
The nurse quickly tracked down the nursing assistant who had given the patient his morning care. The assistant admitted she'd taken the pad off, thinking it was an adhesive bandage covering an intramuscular injection site. The nurse then explained that the pad was a form of medication, not a bandage, and was not to be removed except by a nurse or doctor.
You can avoid a similar error by making sure all personnel involved in direct patient care are kept up to date on the products and equipment they're likely to encounter. Good communication can prevent errors.