"I'm Delia Caballero, a Registered Nurse at Community Medical Center. On Jan. 7, 2001 at approximately 9:40pm I went in the Med. Room to wash my hands. Then I remembered that I need to give a pain medication to my patient in Rm. 5301A, PATIENT A.

I didn't have my care plans with me, so I went to the Med Pyxis and took an activity summary for this patient so I would know the medication and the last time it was given.

The patient's ordered pain medication was Darvocet N100. There were 2 Darvocets taken out at 2 different times and a morphine PCA 30 mg taken out at approximately 6:58pm. I went to my charge nurse, Nancy Stetz and asked her if there's a patient on PCA but there was none. Then I told her what I just found out and then she reported the incident to the nursing supervisors on the night shift, D. Santi RN & C. Reynolds RN."  


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