S13 · Wrong medicine or dose
Risk Safety and protection
Definition
Errors in drug, dose, time, route, or patient may cause harm.- Busy ward
- similar drug names
- poor handwriting
- weak checks
- lack of knowledge
- Near-miss reports
- wrong patient or dose
- unexpected drug reaction
📋 Scenario
A nurse prepares evening medicines on a busy ward where two patients have similar names.
Subjective (S): Patient: "My name is Mr. Khan, not Mr. Khalid."
Objective (O): Two patients with similar names on the ward; busy shift; two similar-looking drug names on the chart; wristband not yet checked.
Assessment tools for this scenario: CP-SAFE Safety & Falls Score
Validated scales to consider: Morse Fall Scale
**CarePath diagnosis:** Wrong medicine or dose related to similar names, similar drug names and a busy ward (risk factors); no signs of the problem are present yet.
**Interventions and rationale**
| Intervention | Rationale |
|---|---|
| Check the patient's name band and ask the patient to state their name before every medicine. | Two identifiers, the wristband and the patient's own spoken name, catch mix-ups that one check alone can miss, which matters when two patients have similar names. |
| Check drug, dose, time, route and allergies against the order. | Checking each element against the order, including allergies, stops errors in drug, dose, time or route before the medicine reaches the patient. |
| Mark similar-name patients with an alert. | An alert on similar-name patients warns every staff member to take extra care, so the risk of confusing the two men is lowered. |
| Avoid interruptions while preparing medicines. | Interruptions break concentration and are a major cause of slips in drug preparation, so a quiet, uninterrupted process keeps checks accurate on a busy ward. |
| Report and record any error or near miss. | Reporting errors and near misses lets the team find weak points in the system and fix them before a patient is harmed. |
**Expected outcomes**
- No wrong-patient or wrong-dose event during the shift.
- Two identifiers checked for every medicine.
- Near misses reported.
**Linking the data to the diagnosis**
The scenario shows a nurse preparing evening medicines on a busy ward with two patients who have similar names. Mr. Khan has said, "My name is Mr. Khan, not Mr. Khalid," the chart holds two similar-looking drug names, and the wristband has not yet been checked. No wrong drug or dose has been given, so this is a risk statement, not an actual error, and it rests on risk factors only. The plan aims to keep the shift free of wrong-patient or wrong-dose events. The nurse checks two identifiers for every medicine and reports any near miss, as the expected outcomes require.
CarePath diagnosis
Wrong medicine or dose related to similar names, similar drug names and a busy ward (risk factors); no signs of the problem are present yet.
Interventions and rationale
Listed in priority order.
| Intervention | Rationale |
|---|---|
| 1. Check the patient's name band and ask the patient to state their name before every medicine. | Two identifiers, the wristband and the patient's own spoken name, catch mix-ups that one check alone can miss, which matters when two patients have similar names. |
| 2. Check drug, dose, time, route and allergies against the order. | Checking each element against the order, including allergies, stops errors in drug, dose, time or route before the medicine reaches the patient. |
| 3. Mark similar-name patients with an alert. | An alert on similar-name patients warns every staff member to take extra care, so the risk of confusing the two men is lowered. |
| 4. Avoid interruptions while preparing medicines. | Interruptions break concentration and are a major cause of slips in drug preparation, so a quiet, uninterrupted process keeps checks accurate on a busy ward. |
| 5. Report and record any error or near miss. | Reporting errors and near misses lets the team find weak points in the system and fix them before a patient is harmed. |
Expected outcomes
- No wrong-patient or wrong-dose event during the shift.
- Two identifiers checked for every medicine.
- Near misses reported.
Linking the data to the diagnosis
The scenario shows a nurse preparing evening medicines on a busy ward with two patients who have similar names. Mr. Khan has said, "My name is Mr. Khan, not Mr. Khalid," the chart holds two similar-looking drug names, and the wristband has not yet been checked. No wrong drug or dose has been given, so this is a risk statement, not an actual error, and it rests on risk factors only. The plan aims to keep the shift free of wrong-patient or wrong-dose events. The nurse checks two identifiers for every medicine and reports any near miss, as the expected outcomes require.