Question

Case Study – 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 future.

What are the management issues that need to be addressed in the case?

Should the nurse have questioned giving this large amount of insulin without checking with the doctor?

Should the pharmacist have questioned the dosage?

Answer 1

What are the management issues that need to be addressed in the case?

Management can also sometimes be responsible for making medication errors, so it is important that they understand the consequences of these mistakes. A systematic review of the root causes for the error must take place with the staffs involved. All medication errors have consequences, be they major or minor. However, regardless of what the consequences might be there should always be a review, including the asking of questions. Medication incidents should be regularly monitored, reported and investigated; and that action is taken to reduce the risk of adverse medication events. Complete medication orders are critical to helping prevent medication errors and should include the patient’s name, generic drug name, trademarked name (if a specific product is required), route and site of administration, dosage form, dose, strength, quantity, frequency of administration, and the prescriber’s name. The desired therapeutic outcome for each drug should be included. Illegibly handwritten prescriptions and orders that are unclear, ambiguous, or overly complex are commonly implicated as causes of medication errors. Computerized prescribing systems, bar-coded medication systems, and cross-checking by others (for example, pharmacists and nurses) can help to intercept such errors. Use care with zeros and decimal points. The misusage of leading decimals and trailing zeros can be dangerous. The adage “always lead, never follow” can help mitigate errors, which can lead to 10-fold or 100-fold dosage errors (eg, always write 0.1, never write 1.0).

Should the nurse have questioned giving this large amount of insulin without checking with the doctor?

Evaluating the root cause of medication errors is essential to implementing changes to medication use systems that can prevent the same errors from occurring in the future. Nurses have an important role in detecting, reporting, preventing and investigating medication errors. ‘However, nurses can also sometimes be responsible for making medication errors, so it is important that they understand the consequences of these mistakes. A systematic review of the root causes for the error must take place with the staffs involved. All medication errors have consequences, be they major or minor. However, regardless of what the consequences might be there should always be a review, including the asking of questions. Medication incidents should be regularly monitored, reported and investigated; and that action is taken to reduce the risk of adverse medication events.

Provide Education regarding the concentration of insulin products, the differences between insulin syringes and other parenteral syringes, how to measure doses, recognition of safe dosage ranges, and how to administer the drug, should be provided to all who might prescribe, prepare, and/or administer insulin. Restrict insulin preparation and administration to those who have demonstrated competency.

Should the pharmacist have questioned the dosage?

Yes the pharmacist should be questioned for the dosage. Illegibly handwritten prescriptions and orders that are unclear, ambiguous, or overly complex are commonly implicated as causes of medication errors. Prescribers should review all drug orders for accuracy, completeness, and legibility immediately after they have prescribed them. If there is ever a question about legibility of a handwritten prescription, the pharmacist or nurse should always clarify the order with the prescriber.