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Robert Brewer, age 5, was hospitalized for measles. Robert Brinson, also age 5, was admitted after he suffered a severe asthma attack. The boys were assigned to adjacent rooms on a small pediatric unit, and each boy had a nonproductive cough as a result of his condition.
During morning rounds, Robert Brewer's nurse took her patient's vital signs, then told his mother she had to get an expectorant the doctor had prescribed for his cough. When the nurse returned with the drug just 5 minutes later, the boy's mother told her Robert had already been given his medicine.
Puzzled, the nurse questioned Mrs. Brewer. She explained that another nurse had come in and asked her if the patient's name was Robert. When Mrs. Brewer answered yes, the nurse said she had the medicine for Robert's cough, and she gave it to him. Mrs. Brewer said she didn't know the name of the medicine, but added that the nurse had made Robert "breathe it in through a mask."
The nurse quickly went to the nurses' station to try to find out what had happened. There, she found a newly assigned nurse charting that she'd given Robert Brinson his prescribed mucolytic acety1cysteine (Mucomyst), which is administered with a nebulizer. Robert Brewer's nurse then realized that the other nurse, who was unfamiliar with the patients on the pediatric unit, had mistakenly given the mucolytic intended for Robert Brinson to Robert Brewer.
Both nurses went immediately to Robert Brewer's room and checked his condition. The mucolytic hadn't seemed to do any harm; in fact, it actually appeared to have improved his cough. But of course, any medication mix-up is potentially serious and a cause for concern.
This mix-up began when the newly assigned nurse obtained the prescribed Mucomyst for Robert Brinson. As she was walking down the hall, she realized she was unsure of his room number. But she spotted a young boy, so she entered the room and asked if he was Robert, adding that she had the medicine for his cough.
Unfortunately, the nurse had entered Robert Brewer's room. And because Mrs. Brewer knew her son was supposed to be given some cough medicine, she assumed that Robert's nurse had asked this nurse to give it to him.
This error could have been prevented if the newly assigned nurse had identified the patient correctly-by checking his identification band. Asking a patient (or family member) to confirm his name is not foolproof. A patient who is feverish, in severe pain, sedated, or preoccupied by his illness could easily misunderstand your question and give you inaccurate information. Similarly, a distraught family member may also respond inaccurately.
So always check the patient's identification band before giving medication, even if you think you know him by sight. That's the only way to confirm the first "right" of medication administration: the right patient.