When preparing the morning medications for Mr. Smith, the nurse notices digoxin in his med drawer. He does not have an order for digoxin on his medication administration record. What should the nurse do?


•This is a near miss since the incorrect medication was placed in the patient's med drawer but was not administered to the patient.

•In addition to sending the medication back to the pharmacy, the nurse is responsible to report the near miss to prevent future errors. Every hospital has an incident reporting system either online or on paper forms. These incident reports are not meant to place blame but are used to identify process issues that can lead to errors.

•There are many steps in the process of medication administration where errors can occur. The nurse is responsible to protect the safety of patients by identifying and reporting near-misses or errors.

Incorrect options:

•Giving this medication to the patient would be an error.

•Sending an e-mail is one way to communicate this near miss, but putting the information in an incident reporting system allows pharmacy and nursing leadership to both have access to the report and work on a solution.

•It is unacceptable to throw the pill in the trash and ignore the near miss. The medication cannot go into the regular trash and the near miss must be reported.

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