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A patient who'd just had a pacemaker implanted was to have his incision cleaned with hydrogen peroxide. His nurse poured some peroxide into a medicine cup and set it on the patient's bedside table, saying, "Here's your hydrogen peroxide-I'll be right back." Then she left the room to get some gauze pads.
When she returned a few minutes later, the cup was empty.
The patient, thinking it was medicine, had swallowed the hydrogen peroxide. The nurse called the doctor, who decided an antidote was unnecessary. The patient complained of a burning mouth and stomachache but was otherwise unharmed. However, he was so upset by the incident that his family transferred him to another hospital.
The lesson is clear: A disinfectant, antiseptic, soap, or other substance left at the bedside in a medicine cup can easily be mistaken for a medication. Usually, you shouldn't leave any substances (including medications) at the bedside. But if you must leave something (e.g., an antiseptic or soap for a patient doing his own wound care), be sure you also give him clear explanations of what it is and how to use it.