Possible Scenario
Suppose a patient with cancer has oral Compazine(prochlorperazine) liquid ordered for nausea. Because the patienthas had difficulty taking the medication, the nurse decided to drawup the Compazine in a syringe without a needle to facilitate givingthe medication. The nurse found this to be quite helpful andprepared several doses in syringes without the needles. A nursefrom another unit covered for the nurse during lunch, and when thepatient complained of nausea, the nurse assumed that the Compazineprepared in an injection syringe was to be given via injection. Thenurse attached a needle and injected the oral medication.
Potential Outcome
Then oral preparation may not be sterile and, if absorbedsystemically, could lead to a bloodstream infection. Also, oralpreparations have different preparation agents that likely shouldnot be injected (such as glucose, which is traumatic to veins).
Question:
Describe the clinical reasoning you would use to prevent thismedication error.
