Wrong Patient Error
An oncology patient received another patient's chemotherapy despite verification by two nurses before administration. Typically, the pharmacy dispensed each patient's chemotherapy inside a labeled ziplock bag, which was then taken to the bedside for verification before administration. In this case, the pharmacy sent chemotherapy for two different patients inside the same ziplock bag; both were the same drug, but different doses. The verification process proceeded as usual by taking the ziplock bag to the patient's room. The contents of the bag were removed, at which time the nurses discovered that there were chemotherapy bags for two different patients. They verified the patient (using two unique identifiers) and the medication, but the nurse who then administered the chemotherapy accidentally picked up the wrong patient's bag and hung it. The other bag of chemotherapy was placed back in the ziplock bag and returned to the medication room. Hours later, the error was discovered while looking for the chemotherapy for the other patient. Luckily, the two patients' doses were close enough that no harm resulted. In this case, the wrong bag of chemotherapy should have been removed from the patient's room immediately. But more to the point, pharmacy should dispense only one patient's medications in each ziplock bag (or envelope, etc.). Involving the patient as the final double check might also have averted this error. Also, though not helpful in this particular case, nurses should identify and verify each drug using the label on the immediate product container, not a label on an outer bag or envelope.
An oncology patient received another patient's chemotherapy despite verification by two nurses before administration. Typically, the pharmacy dispensed each patient's chemotherapy inside a labeled ziplock bag, which was then taken to the bedside for verification before administration. In this case, the pharmacy sent chemotherapy for two different patients inside the same ziplock bag; both were the same drug, but different doses. The verification process proceeded as usual by taking the ziplock bag to the patient's room. The contents of the bag were removed, at which time the nurses discovered that there were chemotherapy bags for two different patients. They verified the patient (using two unique identifiers) and the medication, but the nurse who then administered the chemotherapy accidentally picked up the wrong patient's bag and hung it. The other bag of chemotherapy was placed back in the ziplock bag and returned to the medication room. Hours later, the error was discovered while looking for the chemotherapy for the other patient. Luckily, the two patients' doses were close enough that no harm resulted. In this case, the wrong bag of chemotherapy should have been removed from the patient's room immediately. But more to the point, pharmacy should dispense only one patient's medications in each ziplock bag (or envelope, etc.). Involving the patient as the final double check might also have averted this error. Also, though not helpful in this particular case, nurses should identify and verify each drug using the label on the immediate product container, not a label on an outer bag or envelope.
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