Question

A retired 81-year old man with metastatic colon cancer was admitted to an acute care hospital with pneumonia and congestive heart failure (CHF). After his acute hospitalization, he was transferred to a skilled nursing unit to complete antibiotic therapy. Cancer chemotherapy was scheduled to begin after discharge. Three days after transfer to the skilled nursing unit, the patient complained of nausea. Intravenous ondansetron (Zofran) was ordered. Approximately one hour after the first dose of ondansetron, he was found unresponsive and in respiratory distress. Stat labs were ordered, and his blood glucose was 23 mg/dL. The patient had no history of diabetes or hypoglycemia. He was given glucagon and transferred to the intensive care unit. Laboratory studies showed an insulin level of greater than 1500 micro-units/mL (upper end of the reference range: 17 micro-units/mL). Intravenous glucose and glucagon were continued, and his blood glucose stayed in the low 40 mg/dL range for several days. Ultimately, he was discharged without any permanent disability from the event, but he was in a weakened state and his chemotherapy was delayed. The incident led to an internal review of the case. In this skilled nursing unit, many of the nurses remove medications from the Pyxis machine (an automated dispensing device) and insulin from the refrigerator and place them in portable medication carts that are then taken to the bedside. The nurse who was caring for the patient the night of the first ondansetron dose worked infrequently and had an especially heavy workload that evening (she was caring for nine patients on her shift). When her portable medication cart was inspected, ondansetron and insulin vials were found to be next to each other. It was presumed that she mistakenly administered insulin instead of ondansetron.

What factors (human, work load, and environment) contributed to this error?

What recommendations can you make to prevent this type of error in the future?

Answer 1

The factors contributed to this error is work load,as she was caring for many patients.The mistake done as keeping loaded medicines in tray without labelling I the leading cause for this incident.Apart from this a hectic workload may lead the nurse to administer the meficin carelessly

Some of the measures which can be taken in the future to prevent this type of error are

• The management should follow the standard nurse patient ratio (1:2 in ICU,1:4 in Emergency, 1:5 or 1:8 in ward )
• Ensuring labelling of medicine when loaded
• Prepare medication in the concerned patient cabin to avoid error
• Prepare medication just before administering
• Follow the rights of medication administration
• Do not administer medications if confused
• Ask or call for help by informing the in charge or supervisor when there is hectic work
• Document the medication administration