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Experiencing a medication error

June 17, 2013
by Kathleen Mears
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After I first moved to a nursing home, I made sure that I paid attention to the medications I was given. Over time I relaxed, trusted the nurses more, and was not quite as concerned.

However taking bedtime meds still concerned me. I wanted to be awake when I took my meds. I did not like being awakened and having the nurse pour meds in my mouth while I was groggy. When I reiterated each evening that I wanted to take my meds while I was awake, it aggravated the nurse and aides. But I stood my ground.

A few years later at that same facility we had a 7 p.m–7 a.m. nurse who often finished her bedtime med pass late. Staff usually found her watching TV in a resident's room.

At bedtime one evening that nurse gave me my meds, and I went to sleep. The next morning I felt extremely tired and had a hard time waking up. I told the aides I thought I might have taken the wrong medicine or that I might have had a stroke. The aides listened but did not respond.

When my aide was setting me up at my computer, it was hard for me to sit up straight. It was also difficult for me to use my left hand.

As I sat at the computer trying to push myself to do something, the night shift nurse came in with papers in her hand. I said, "Did I get the wrong medicine?" She said she gave me two Halcion, Instead of my scheduled two 2 mg Valium. She explained that Halcion and 2 mg Valium are similar in color and that the female resident across the hall took one Halcion at bedtime to help her sleep.

The nurse completed the paperwork. I asked if I could be given something to counteract the Halcion. She advised that I would have to go to bed and sleep it off.

My boyfriend (at the time) was to visit me that evening. But I told him I was very tired from getting the wrong med and asked him not to come. Then I went to bed and fell asleep.

When I woke up, my boyfriend was in the chair beside my bed. He said he had been sitting there for over an hour while I slept. After I told him about the med error, he decided to visit to see if I was all right.

That medication error frightened me and made me even more determined to take nighttime meds when I am awake and know what I am taking.

Now, if I ever feel strange or overmedicated in the morning I have the nurse check which meds I was given the previous night.

In my 17 years living in nursing homes I have been informed of only one medication error. But that was enough.

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Kathleen Mears

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Kathleen Mears has been a nursing home resident in Ohio for 20 years. She is an incomplete...