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The charge nurse on a busy medicaVsurgical unit was feeling rushed because she was also responsible for administering all the I.V. push medications. While she was making rounds, she was dismayed to see bright red urine in Mr. Gregario's collection bag. She alerted his doctor, reminding him that the patient was receiving heparin. The doctor ordered a stat activated partial thromboplastin time (APTT) test and told her to hold the heparin.
A short while later, when she was preparing to give the I.V. medications, the nurse noted that a dose of heparin was ordered for Mr. Simmons. She carefully prepared the dose, checked it against his medication administration record ... then walked into Mr. Gregario's room and gave the heparin to him.
The nurse was horrified when she realized what she'd done. She called the doctor, who administered protamine sulfate to counteract the heparin's effect; he also ordered another APTT test. Luckily, Mr. Gregario was not harmed by the unordered heparin.
This incident illustrates how even the most careful nurse can make a mistake. In this instance, the busy nurse was so worried about Mr. Gregario and his hematuria-associating his problem with heparin-that she gave the heparin to him.
To prevent such an error, always check a patient's armband before giving him a drug. And even in a pressure-cooker situation, concentrate on one task at a time.