Good Intentions Lead To...Overdose???

Nurses and doctors do everything they can to make the stay of patients to be a good experience.  This includes providing pain control…or at least trying to help with pain control…however sometimes good intentions do not always have good outcomes. 
One of the important lessons nurses are taught in pharmacology class is that many times doses of medications may need to be adjusted for patients.  Yet, sometimes this may be forgotten.
I was caring for an elderly patient one night.   He was complaining of pain in his lumbar back area.  He had fallen earlier that day, so the doctors came up and assessed him and did the battery of tests to make sure there was no injury.  When all the tests were done, the doctors ordered 2 tablets of Percocet to be given every 4 hours. 
I went ahead and gave him the 2 Percocet.  At exactly four hours later he was complaining of pain again.  It was time for some more pain medications, but I was a little hesitant to give more due to a history of chronic renal failure.  I text paged the doctor just to verify the dose and suggested maybe decreasing the dose or increasing the hours between the doses but the doctors did not seem interested in my concern.  I was very careful during the night to make sure the pain meds was not building up in his system.  He seemed to be fine, and in the morning I left for a four day break. 
The next night I was at work, I noticed I was getting this patient back.  I received report and checked his pain meds.  They were the same as when I left before so I didn’t think another thing about it.  I went in to assess the patient and found him to be very lethargic and only responsive to aggressive stimuli (sternal rub) and would only keep his eyes open for a few seconds after being aroused.
Great!!!!  Just what I needed to start my night!
I did a double check to see when his last pain medication was administered.  It had been 15 hours since his last dose.  His vital signs were stable and everything was fine except for his lethargic state. 
I called the doctor, he came up to assess the patient and ordered Narcan to be administered.  Narcan was given and the patient came to.  He was fine, and the doctors left with orders to move the patient to progressive care and a Narcan drip.  The patient was fine and transferred to the other floor.
While doctors and nurses have good intentions, we do not always get good outcomes, but thankfully this patient had a good outcome with just a minor speed bump in his recovery.