Question

• Medication error

  Medication Error Dale Buchbinder You are a physician making rounds on your patients when you arrive at Mrs. Buckman’s room. She’s an elderly lady in her late 70s who recently had colon surgery. She is also the wife of a 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 an 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, and the treating nurse to determine what can be done to prevent this type of error in the future.

• Please answer the following questions.
• Background Statement?

• Major Problems and Secondary Issues?

• Your Role?

• Organizational Strengths and Weaknesses?

• Alternatives and Recommended Solutions?

• Evaluation?

Answer 1

· Background Statement?

Mrs. Buckman 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. The physician somewhat concerned about this observation and decided to check and ask the charge nurse to review the dose of insulin given.

· Major Problems and Secondary Issues?

Medication error: Administering wrong dose that is giving 80 units of insulin instead of 8.0 units

Negligence: Negligence to staff administering the drug which is extraordinarily large dosage. She should cross check the dose before giving the drug with the patient medication file. if she have doubt she should take help.

· Your Role?

· Make the patient stable first.

· Raised an incident form.

· Educate the treating nurse about the incidence, teach the nurse about medication error so that she will not repeat the mistake again.

· Ensure and encouraged the nurse not to make such mistakes again.

· Organizational Strengths and Weaknesses?

Strengths: quickly analyse the situation and try to handle or solved the problem at the same moment. Immediately meeting was done with the charge nurse, the nursing supervisor, the Director of Nursing, and the treating nurse to solved the problem

Weaknesses: Standard operating protocols not followed.

· Alternatives and Recommended Solutions?

Use metric measures while writing doses of medications.

Use the universal metric measures that are preferred by pharmacists and practitioners. When using metric measures, be careful when and where you use the decimal point. For example, when writing dexamethasone 2.0 mg, if the decimal point is not visualized, then the nurse or the pharmacist may think it is 20 mg.

Spervisors or senior staff should check how the staffs are working and check they are following the hospital protocols or not. All nursing staff should be given continuous nursing education, and stay aware of the policy, protocols of the hospital. Standard operating procedures of care should be maintained by staff.

· Evaluation?

It shows the treating staff have lack of knowledge about medication, by giving such huge amount of drug, it might be also negligence of staff and lack of supervision.

Sometimes the hand writing of the physician is not able to read this also can cause medication error.so medication should be written carefully, if possible in capital letter or according to hospital protocol. Such mistakes should try to avoid as much as possible by taking all the necessary steps.