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Case: John Williams, a 44 year-old patient who arrives in the ED with complaints of a terrible headache. He has a blindfold on to shield all light in an attempt to reduce his pain currently reported to be 9/10. After a quick assessment, the physician orders the patient to receive pain medication in the form of a pill. The order reads Norco 7.5 mg - 325 mg two tablets every 4 hours prn moderate pain (6-8/10). Nurse Judy removes the medicine and takes it to the bedside where she has difficulty scanning the medication but the patient is moaning and grabbing his head so she overrides the scanner.
Later, the supervisor asks Nurse Judy why the count is wrong for Norco 10mg -325mg. It is determined that Mr. Williams received a larger dose than was ordered. When Nurse Judy left for the day she met her carpool driver in the elevator who asked her how her day went. The elevator was crowded and Judy was daydreaming but blurted out, "my supervisor got all bent out of shape because I gave Mr. Williams the wrong dose for his pain pill. I'm sure he didn't mind since he went to sleep and no more moaning with a headache. Can you imagine coming to the ED for a headache?"
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