An infant was to be discharged from the NICU on medication. Ruth Murphy obtained the prescription from the provider and instructed the mom to have it filled and brought back to the hospital so she could show her how to accurately measure the dose. When the mom returned from the outside pharmacy with the bottle of liquid, Ruth noticed that it was labeled with the incorrect dosage. It was very possible that the dispensed dosage could have resulted in real harm to the infant. She called the dispensing pharmacy and notified them of the error.
Ruth’s strategy for ensuring that parents know how to measure medications at home was not part of any NICU discharge guideline. This is a process that she uses to ensure that her patient is safe. As a result of this situation and the pro-active intervention of this nurse, the NICU Discharge Criteria has been revised to include teaching parents how to measure all medications to be given at home, including those filled at outside pharmacies.