Pills Can Be Dangerous

As a new nurse, I practiced the “Five Rs” of medication administration with religious devotion:  right patient, right medication, right route, right dose and right time.  Over the next thirty years, I gave thousands of pills to patients.

Early one morning, my fellow RN called out from within a patient’s hospital room, “Getting ready for medical transport, need some help!”

Peeking into the room, “What can I do?”

Tanya replied, “Get Mrs. Smith’s meds.”

I badged into the medication room and carefully selected each of Mrs. Smith’s drugs from the Pyxis medication dispensing machine. Drawers popped open and closed as I moved down the list.

When I returned with the medications, Tanya had been called away. After refreshing the patient’s  water glass, I popped the first pill from the blister pack. Suddenly, I stopped, remembering the recent regulation in 2003 to verify two identifiers. Couldn’t use the room number because patients often change locations within the hospital. And I couldn’t rely on a verbal response from the patient because she may answer to the wrong name. The check had to be a printed patient name and medical record number.  Plus, in this hospital, patient identification was deemed a RED RULE. Adapted from the nuclear power industry, something so critical that it can never be violated. Breaking a red rule three times brought me automatic termination.

I reached for the patient’s wrist and read her armband. To my horror, she was NOT Mrs. Smith. Eight pills almost given to the wrong patient: two high blood pressure, one thyroid, one pain, one nitroglycerin, two vitamins, and a type 2 diabetes med. Panic set in as the power of life and death in those pills gripped me. I felt sick to my stomach and trembled all over. Could barely catch my breath. Visions of having to resuscitate the patient, admit my mistake, and lose my license flashed in my head.

We nurses speak to each other in clipped sentences much the same as other professionals like ship captains, surgeons and pilots. Because of this, I’d incorrectly assumed that Tanya meant for me to bring the medications for the patient in front of us.

The next year, my hospital implemented a computer software program that required us to scan the patient’s identification band against the bar code on the medication to make sure they matched. What a lifesaver for both my patient and me.

Marilyn Barton
Hampton, Virginia