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A night nurse was preparing medications for three patients when an elderly woman who had Parkinson's disease asked for some aspirin. After confirming that aspirin had been ordered p.r.n., the nurse poured two tablets into another medication cup, then picked up the four cups and started for the patient rooms. Recalling how the elderly woman frequently complained about getting her medications late, the nurse gave her the aspirin first.
As soon as the patient swallowed the tablets, the nurse realized she'd made a mistake. What she'd just given the patient was not two aspirin tablets but three morphine sulfate tablets meant for a patient who had cancer. She had mixed up the cups as she tried to carryall four at once.
The nurse notified the doctor and stayed with the patient while another nurse finished administering the medications and obtained a new dose of morphine for the cancer patient. Luckily, the elderly woman didn't develop respiratory depression or other adverse reactions to the narcotic.
Such an error is easily prevented: Never handle more than one patient's medications at the same time. And be sure to keep medications in their unit-dose package until you are at the patient's bedside.