Question

Mivacurium (Mivacron), instead of metronidazole, was accidentally administered to several patients at a large hospital. Three patients went into respiratory arrest, and one died. A multidisciplinary team was assembled to analyze the event and determine actions that could be taken to prevent similar errors from recurring. Here’s what they found: A technician pulled several bags of foil-wrapped IV items from the bulk IV storage area. At the time, it was thought that metronidazole was the only medication in the pharmacy that was packaged in foil outer wraps. However, the anesthesia department had ordered samples of mivacurium from a drug representative without notifying the pharmacy. A shipment of sample products had been delivered to the pharmacy the previous day and placed into stock without notice. The technician placed pharmacy-generated labels that said “metronidazole” on the foil outer wrap of each bag. The pharmacist checked the bags and the computer-generated labels against the physician’s order. No one noticed that the foil-wrapped bags actually contained mivacurium. The mivacurium was sent to the nursing unit mislabeled as metronidazole. When the nurses received the bags, they noted the pharmacy label for metronidazole on the outer foil wrap. They verified the drug name on the pharmacy label with the transcribed order on the patient’s MAR. The medication was administered IV to four patients, still packaged in the foil outer wrap. All four patients went into respiratory arrest and one died several days later as a result of the error. The incident resulted in the termination of a pharmacist and a pharmacy technician and the suspension of several nurses. a. What went wrong in scenario b. what steps might the healthcare organization take to prevent future instances, and what policies/procedures should be implemented based on this analysis

Answer 1

a.

Answer: In this schenario, the main problem is negligence related medication error in the workplace and lack of communication between the anesthesia department and the pharmacist. In a hospital the stock of drug or indent of drugs are handle by the pharmacy department, so the anesthesia department also should inform them. Also the cross check of the drug is one of major role of pharmacist and the nurses to do, but fail to follow the cross check before administration.

b.

Answer: The next steps that can be taken by the organisation is that education regarding the important of proper communication and cross check the medication and lebel it. The nurses also have to cross check the medication before administering by two nurses to prevent from medication error. Educate them how to crosscheck the medication. So, education is the piwerful weapon to solve every problem.

After the cross check, documentation should be done properly in the nurses notes and should be signed by the accountable nurse who administerd the particular drug and the other nurse who cross check before the administration. The documentation should be check again by the incharge of the ward.

Minimize the workload and the do distrubance during the medication time to the nurses because of this may leads the nurse to forget cross checking the medicine.

Maintain a indent record book. Maintain the list of drugs with the number. The incharge should cross check everyday the number of drug store in ward and how many are used for which patient.

Proper labelling of the medication after the cross check of the medication should be done.