Nola writes:...As I began to prepare to take her pressure she did mention not to use the one arm as she had a patch' on it. Her BP was in 170/90 range, but she said it was better than previous readings which necessitated the doctor ordering a Clonidine patch. She left the office and would return again for a check. On Tuesday, I was again in that Nursing Office and my resident with elevated BP returned. She told me the doctor ordered a second patch! I took her pressure and found it still elevated, then checked the BP in the other arm. The pressure was even higher. The patch on the right arm was not completely affixed to the arm and I peeked under it and didn't see anything but the beige wafer. I explained to the resident that there was usually a clear wafer that contained the medication and the beige wafer was just to protect the medication delivery. She said that she ONLY PUT ON THAT BEIGE WAFER, and didn't recall anything else in the packet. I consulted a drug book, but it wasn't clear about the medication delivery method but I asked her to please go home, and check the packaging and directions that came with it. She went home and within 20 minutes called me back. She was shocked. Yes! There in the package she found the thin wafer that had the medication in it. She thanked me profusely for making her check this out. She had said no one mentioned to her that there would be 2 components of the patch, not the doctor or the pharmacy. She called her ordering physician to let them know what happened and received new instructions about re-applying the new 2-part patch.

Without Nola Sarama really paying attention, this woman could have had serious health consequences.