I know he is a Travel RN, but he is wonderful, and this was a great catch! A CMO patient was to receive 4 mg crushed hydromorphone. The nurse crushed the first tablet and was starting to open the second tablet when the label of the drug came off the medication package.

There was a second label still on the package that had been underneath the hydromorphone label. This label was torn slightly, but it was clear that the name of the medication was not the same. The nurse took the already crushed medication and the unopened package out of the room and brought them to charge.

Upon assessment, the package that was crushed also had a different label underneath. A picture was taken of the unopened package with two labels and sent to our manager. The packages were then taken to the floor pharmacist to address the concern about the medication. The pharmacist opened the unopened package and was able to confirm that the pill inside was indeed Hydromorphone.