Question

NURSING

SITUATION # 3
On a busy day in a clinical department, patient X's drug kardex was placed in Patient Y's place. Patient Y had been admitted on the 11-11 AM shift and had only an intravenous solution ordered and was pending. of the doctor's evaluation in the morning. When the delivery was made on duty in the report, it was reported that patient X was discharged, but the doctor indicated that he take the oral medications he had ordered for breakfast before leaving. The nurse in charge was distracted by several calls from the patients in the rooms and did not notice that the kardex were reversed, so she proceeded with the administration of the medications. Patient Y received the medications from Patient X. When the error was identified, discharge from Patient X was delayed.

1. What error do you identify in the situation?
2. Which of the National Patient Safety Goals was not met?
3. What information does the nurse need to know before administering the ordered medications to the patient?
4. How could the error be prevented?
5. What ethical-legal repercussions could arise in this case?

Answer 1

1. Error occured in the situation:

Medication error is occurred in the situation due to Nurse's negligence or act of omission. Nurse misidentified the patient( patient Y) and administered the wrong medication, that prescribed for another patient ( patient x). Medication Error is a failure in the treatment or an accidental wrong action in the treatment process, which may result in harmful reactions in patient.

2. National patient safety goals:

'National patient safety goals ' are established by The Joint Commission to protect the patient's rights   and it is getting revised frequently . As per National patient safety goals 2020, the error happened in the above given scenario, not met the first goal. The first goal is ' Identify patients correctly. Here due to the misplacement of drug kardex , nurse perceived   the medication order wrongly and she omitted her responsibility of identifying the patient correctly by checking atleast two identities of the patient.

3. Before administering an ordered medication to the patient , nurse need to know about the patient identity and the diagnosis, and she has to check and validate the medication and critically think about the uses and contraindications of the medicine. She can clarify her doubts , if any with physician or pharmacist.

4. According to ' National patient safety Goals ' to prevent misidentification of patient or to identify the patients correctly , the nurse has to:

* " Use two identities of patient , such as Name and Date of Birth " . She has to call out the full name of the patient and use a second identity information to make sure that the patient is same as in the record. She can check the patient's records for previous medicine . If a new medicine written in patient's record, she has to clarify about that medicine with physician or pharmacist. Here the nurse neither identified the patient correctly by calling his name nor ensured with date of Birth .

5. Ethical and legal consequences:

Legal and ethical consequences may based upon the effect or the adverse effects of the drug on patient's body. If the effect may worsen patient condition or cause a new condition in patient, both may negatively affect the nurse's status. If it is a neutral medication , nurse may get protected . But the consequences of wrong administration are affecting patient's condition negatively,then the patient can file a case against nurse and the legal procedures and penalties attracted towards nurse for not identifying the patient correctly. She even breached the ethical principles of Beneficience and non - maleficence, that she done a harm to the patient. If the effect is deteriorating patient's condition, then the professional organisation also may take the steps against the nurse.