"Early in my career, I was working at a large nursing home on the evening shift. One evening, during medication passing, I realized towards the end of the pass that we had one dose that didn't belong to the final two patients on the unit. At that time, our staff was preparing the medications on a cart and we would pass in a team of two. We didn't carry along patient documentation during passes and a certain mistake was made by giving one patient the wrong medication. Through a process of elimination based on our tracking chart back at our station, we thankfully realized that a patient was accidentally given a dose of ibuprofen rather than his other pain medication. The ibuprofen would do no harm and we could reissue a safe dosage of his other pain medication. Fully realizing that the mistake could've been much worse, we implemented some new procedures to ensure that we were giving the right meds at the right dose to the right person each and every time."