Question

Medication Error Scenario Event Description Ellie, an 85-year-old nursing home patient, was admitted to the hospital for hip replacement surgery following a left hip fracture. She has a history of cognitive impairment and congestive heart failure. Her admission vital signs were normal. Ellie’s daughter provided an admission history for the nurse. The daughter informed the nurse that she did not have a written list of medications, but could remember all prescribed medications and dosages. The nurse asked the daughter to provide a written medication list to the nursing staff next time she visited. A medication reconciliation form was completed that included an order for Lasix 20 mg. as well as a number of other medications. All medications were verified with the hospitalist on call and entered into the electronic health record. Unfortunately, the patient’s daughter gave inaccurate information to the admitting nurse. Her mother was actually prescribed Lasix 40 mg daily. Additionally, the daughter forgot to provide a written medication list to the nursing staff. Ellie’s surgery was eventful in that she experienced significant blood loss during surgery. Ellie’s daughter was visiting her mother on the first day post-op when the staff nurse was giving medications to Ellie. The nurse scanned the patient’s identification band and medication, and explained she was administering Lasix 20 mg. Her daughter informed the nurse that the medication color was different than her mother received at home. The nurse verified the order and told the daughter that she is to receive Lasix 20 mg. Ellie was weighed on the second day post-op with a noted 3 lb. weight increase from admission. The weight was recorded in her chart with an indication that a call would be placed to Ellie’s physician. Orders were received: Give Lasix 40 mg now and continue daily weights; call physician for weight gain of 2 lbs or more. Continue to monitor Complete Blood Count (CBC). On the fourth day post-op, the patient’s hemoglobin and hematocrit were noted to be above normal and the physician ordered 1 unit of packed Red Blood Cells (RBCs) to be administered intravenously along with Lasix 40 mg also intravenously. The physician’s orders were written at 09:00am; the IV was initiated at 10:00am, but the ordered medications were not administered yet. Ellie’s nurse was delayed in delivering the packed cells since no IV Lasix was available and an emergency occurred with another patient. At 3:00pm Ellie had not yet received packed RBCs and it was noted she was experiencing extreme difficulty breathing and extreme swelling. Her vital signs were well above normal with a Blood Pressure of 190/110 and Heart Rate of 120. Her lungs were assessed and were moist with crackles throughout. The nurse initiated the rapid response team. The attending physician was called. The physician ordered Ellie to be transferred back to the hospital from the nursing home. While awaiting the ambulance, Ellie went into cardiac arrest and could not be resuscitated.

Question:

Complete the Fishbone Diagram based on the scenario.

At the bottom of the Fishbone Diagram or on the next page, answer the question, "What corrective actions should be taken to ensure that a medication error like this does not happen again?"

Answer 1

Fishbone diagram :-

Preventing Medication errors :-

Understand and follow P & P governing med administration

Minimize verbal or telephone orders

Use only approved and appropriate abbreviations -no trailing zeros, etc.

Do not try to decipher illegibly written orders - call and clarify

NEVER ASSUME anything about items not specified in a drug order - if it's not written, don't give it.

Do not hesitate to question a medication order for any reason when in doubt

Develop a routine

ALWAYS DO 3 CHECKS AND VERIFY 6 RIGHTS

Read labels carefully

Look up a drug if you're not familiar with it

Do not confuse measurements

Question calculations with multiple tablets

LISTEN TO AND HONOR ANY CONCERNS EXPRESSED BY PATIENTS REGARDING MEDICATIONS

STOP AND THINK; DON'T RUSH!