| Contents | Previous | Next |
A nurse on an oncology unit was preparing to flush a patient's heparin lock. A doctor came over to her, said he was going to perform a bone marrow biopsy on another patient, and told her to get the biopsy tray immediately. He told another nurse to prepare an injection of 3 mg of morphine.
The first nurse stopped what she was doing and got the tray. When she brought it to the patient's room, she saw the doctor administering an injection into the patient's I.V. line. He then proceeded with the biopsy. The second nurse came in just as he was finishing the procedure.
After they picked up the equipment and left the patient's room, the second nurse said to the doctor, "I guess you didn't want this after all." She showed him the syringe of morphine he'd told her to prepare. The doctor looked at the empty cartridge on the tray. He'd given the patient the heparin flush the first nurse had been preparing when he came to the unit. She'd set the syringe down when she went to get the biopsy tray, and the doctor had picked it up, thinking it was the morphine he'd ordered.
The patient wasn't harmed by the heparin, but he suffered unnecessary pain during the biopsy. Of course, the doctor was at fault for not reading the cartridge's label before administering the medication. But the first nurse should not have left a medication untended. The lesson: When you're preparing medication, finish administering it and chart what you've done before going on to the next task.