Question

Case Study 24 – Medication Error

You are a physician making rounds on your patients when you arrive at Mrs. Buckman’s room. She is an elderly lady in her late 70’s who recently had colon surgery. She is also the wife of prominent physician at the hospital. She has been known to be somewhat confrontational with the nursing staff. However, today she states she was just given a shot of insulin to cover her elevated blood sugar and the amount of insulin did not seem to be the usual amount. Even though Mrs. Buckman often complains, you are somewhat concerned about this observation and decide that it would be best to check on this.

You ask the charge nurse to review the dose of insulin given. She, in turn, finds Mrs. Buckman’s nurse, who states that, as ordered she had given the patient 80 units of insulin. You immediately become quite alarmed, as this is extraordinarily large dosage. You make sure that the patient is given a large amount of glucose supplement and that her blood sugar is monitored every 15 minutes for the next two hours. To follow up, you also review the chart and note an order from the house physician to give Mrs. Buckman 8.0 units of insulin. You can readily see how this could easily appear to be 80 units.

You meet with the charge nurse, the nursing supervisor, the Director of Nursing (DON), and the treating nurse to determine what can be done to prevent this type of error in the futur

Part 1: Answer discussion question 6 in Case 24. • What mechanisms can be put in place to prevent this form occurring in the future?

Part 2: Evaluate this case in accordance with Joint Commission’s guidance for Sentinel Events for hospitals. • How does this case meet/or not meet the criteria? Explain your answer

Answer 1

Here in. Mrs. Buckman case the medication error occurred as the precriber didn’t follow standard method of writing dose instead of 8 he wrote 8.0 which was mistakenly read 80 by the nurse.It is non compliance with order writing guidelines of physician.And also lack of knowledge of nurse in the action and overdose effects of drug.

PART 1:Mechanisms can be put in place to prevent this form occurring in the future:

Make sure all the staffs including doctors and nurses should be aware of writing guidelines which is commonly accepted.

Nurse should have knowledge regarding the drug which is administered like action, indication, contraindication, side effects and overdose.

Thorough checking of medicines before the administration

PART 2: Sentinel Event is defined by The Joint Commission (TJC) as any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient's illness.Here in Mrs.Buckman case in hospital which is a health care setting, wrong dosage of medication was given which can affect her with serious physical effects, and caused psychological trauma as well as if unnoticed could have resulted even in her death.Therefore we can consider this event as sentinel event.