Question

When medications were administered during the night shift, a patient refuses to take his 0200 dose of an antibiotic, claiming that he has just taken it. What actions by the nurse would ensure sound decision making and maintain patient safety? Indicate with References

Answer 1

Go to the patient table, recheck the prescriber's order against the medication administration record or profile, and check the dispensing system or medication record to determine whether a dose was given and signed off by another nurse. Do not rely only on the patient words.

Never assume that the patient is unaware of his or her medication; always double-check to be safe. If all records and orders have been checked, and the nurse is certain that the drug has not been given, then the nurse proceeds with medication administration. A simple explanation could then be given to the patient. If the patient continues to refuse the medication, document this in the nurses' notes and report it to the charge nurse or nurse supervisor and to the prescriber.