Question

A nurse at a Minnesota nursing home transcribed a resident’s medication order on a different person’s chart. Her colleague also failed to properly match the drug with the patient’s medication administration record (MAR).

How It Happened

According to the Minnesota Department of Health’s official investigative report, two nurses neglected to follow established facility procedures for handling the drug in question. Specifically, the nurse who signed off on the medication put the order on the wrong resident’s MAR. The second nurse failed to double-check the order against that wrong patient’s chart. Additionally, the entire

care team failed to catch the errors for nine days.

The Result

The resident was taking the drug, an anticoagulant, because they had a history of developing blood clots. During the nine-day window, the resident developed clots in their brain that eventually caused a large—and fatal—ischemic stroke.

1. What do you believe contributed to the nurse's error?

2. As a nurse, what would you do to help prevent the error from occurring?

Answer 1

Answer 1

Factor contributing to nurse error

A. Inadequate nursing staff

B overload of patient

C. Error in reading of prescription

D. Mental stress in work area

E mental stress in. Personal life

F lack of proper knowledge

G over confidence in work

H lack of follow protocol to nurset patient

I error in writing prescription by physician

J failed to double check prescription

K inadequate information flow

L technical failure

M inadequate protocol of hospital

Answerv2

Error can be prevent from occuring

1. Ensure the five rights of medication administration. ...
2. Follow proper medication procedures. ...
3. Double check—or even triple check—procedures. .band medicines..
4. Have the another nurse read it back. ...
5. Consider using a name of patient
6. Place a zero in front of the decimal point. so that drug quantity should be given proper always ensure to give value of medicine weight and unit
7. Document everything

Nursing care of stroke patients

• Positioning. ...
• Prevent flexion. Apply splint to prevent flexion of limbs
• Monitor vital stastics especially blood pressure frequently
• Prevent adduction. it can be provided by putting pillow under upper limbs
• Prevent edema. ...elevate the legs
• Full range of motion. ...
• Prevent venous stasis. ...by exercise
• Regain balance. ... Teach patient to get balance in sitting position
• Personal hygiene