medication incident

  1. In nursing school we learned never turn your back on a sterile field.
    This morning I learned.... never turn your back on a nursing home resident's pills. I was passing early morning meds near the end of my night shift. I went to Mr and Mrs M's room, with 2 souffle med cups, one for him and one for her, his eye drops and nitro patch. I had forgotton her calcitonon nasal spray, so after giving Mr his pills, I left everything else and said I'll be right back. I grabbed her spray and when I got back he said, "I took that one, too." He took his wife's pill! It was only calcium with vit D, but I still need to do something about it. It's the weekend and I don't know how to document what happened. The nurse coming on this morning said to ask the DON. She won't be there until Monday. It's scary how a careless mistake can happen so quickly.
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  2. 3 Comments

  3. by   AcosmicRN
    :uhoh21: The posters below are correct: follow your facilities guidelines for medication errors.
    Last edit by AcosmicRN on Jun 19, '04 : Reason: I said the wrong thing
  4. by   donmomofnine
    I'm so sorry, but I think you learned something from this and that is what's important ~ to keep our mistakes little and to learn from them! I don't know what your facility protocol is, but we fill out a medication error report. The physician and family are notified as well, and then the resident is observed for any side effects from taking the wrong medication. In this case, I don't think you have anything to worry about! A good rule is, of course, never leave a resident's meds out of your sight, but also not to carry two residents medications at the same time.
  5. by   chris_at_lucas_RN
    You did exactly the right thing, telling the nurse coming on this a.m. I'm assuming there was an RN on during your shift and you also reported it to him/her.

    I'm betting there is an incident report form that needs filling out.

    I would document the event and the fact that you told the nurse, noting times and details, just for your own reference. Then you have that to show the DON on Monday when she comes in.

    And of course, neither you nor I (thank you! I'm learning from your experience!) will ever turn our backs on patient's meds.

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