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A nurse was hospitalized for removal of a cyst. Her doctor ordered a preoperative infusion of cefazolin, 1 gram in 100 ml of D5W. When the container was hung, the nurse-patient instinctively checked the label. She was surprised to see another patient's name on it, even though the drug and dose information was correct.
She told her nurse about the label. The nurse explained that although the label had someone else's name on it, the bag contained the drug prescribed for her. The pharmacist had prepared the infusion for another patient before learning that the order had been discontinued. He said it was okay to use it for the nursepatient.
Not satisfied with this explanation, the nurse-patient protested to her doctor. On his order, a new infusion was prepared, labeled correctly, and hung.
This incident shows poor practice on the part of both the pharmacist and nurse Any medication dispensed but not used should be returned to the pharmacy. If it can be used for another patient, it must be checked to see that it's been sealed and stored correctly, then relabeled.
Violating this protocol can easily lead to medication errors. Besides, common sense tells you that giving a patient a medication that has someone else's name on the label is no way to gain that patient's trust.