You are newly graduated nurse on your first ward rotation of a new graduate transition program in a major tertiary hospital in Sydney. You have been working on this ward, which is the Coronary Care...

You are newly graduated nurse on your first ward rotation of a new graduate transition program in a major tertiary hospital in Sydney. You have been working on this ward, which is the Coronary Care Unit, for five months now and are nearing the end of your six-month ward placement. You have really enjoyed working in this unit as the Nurse Unit Manager is supportive, you have formed good working relationships with most of the nurses and feel confident working within your scope of practice most shifts. Most shifts are fast paced, but you like this and it has piqued your interest in high acuity nursing.
You have started a busy morning shift and you are doing your medication round when a colleague, Mary, asks you if you could do a S8 drug check with her. You happily oblige as you also need an S8 drug for one of your patients as well. You both go to the S8 drug cupboard. You have the patient medication charts in front of you and the S8 book. Your colleague counts the S8 medication that is required for her patient, Endone 5mg, and places a tablet in a medication cup. Then your colleague counts the S8 medication that is required for your patient, Targin 5/2.5mg, and places that tablet in another separate medication cup as not to mix them up. Together you are happy that the drug counts are correct, and your colleague Mary locks the S8 cupboard and takes the patient medication charts in her hands, whilst you take both the medication cups with the separate S8 drugs in them in your hands.
You go to Mary’s patient first. Together you complete the patient checks and three drug checks, and you hand over the medication cup to the patient which has a tablet in it. The patient puts the tablet in their mouth and swallows it with a glass of water. You both sign the S8 book to register the patient has taken the tablet and walk out of the room. Mary and you both go to your patient’s room and you start to complete your patient ID and drug checks. You look down at the medication cup and realise that you don’t have a Targin tablet in the medication cup, you have the Endone tablet instead.
You look at Mary and tell her you have just realised that you handed her patient the wrong S8 medication. Mary looks at you and starts to say she knew she couldn’t trust you yet and that you are in big trouble. Your heart sinks and know you must act fast to inform not only the patient, but also the doctors and your Nurse Unit Manager (NUM) immediately.