Case Error Medication
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2011 issue Problem: When you think of “wrong patient” medication errors in inpatient settings, the most common scenario that comes medication error case studies to mind is a nurse walking into a patient’s room and
Medication Error Story
administering medications intended for one patient to another patient—often a roommate. Perhaps the patient had switched medication error case report hospital beds with his roommate to be closer to the window, or he was sitting on the edge of his roommate’s empty bed. Maybe the nurse had verified
Nursing Medication Error Case Study
the patient’s identity during initial drug administration but failed to check it again during subsequent administrations that day.1 Or the process of verifying the patient’s identity was interrupted by a visitor asking a question, and the nurse simply forgot to complete the verification process. In any case, one fundamental cause of these errors is a cases of medication errors by nurses flawed or absent patient identification process. However, “wrong patient” medication errors can occur for a variety of reasons at any point in the patient encounter or during any phase of the medication use process. Examples of hazards, near misses, and actual “wrong patient” errors follow. Fictitious names are provided when necessary to convey the basis of the error. Patient Registration Omitting junior/senior designation. A patient’s son, John Jones Jr., was registering to donate stem cells for his father, John Jones Sr.1 After confirming the son had previously been a patient in the hospital, the registration clerk located “John Jones” in the master patient list, printed an armband, and placed the armband on his wrist. The clerk was focused on the technical aspects of entering data, and little attention was given to verifying the patient’s identity before applying the armband. A clerk later realized that both father and son were wearing identical armbands. Thus, any medications prescribed for the father could have been
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Medication Error Scenarios
by Type Search Verdicts & Settlements Medication Error Lawsuit Resulting in Death of Woman
Medication Error Case Scenarios
Settles for $1.25 Million 2011 Medical Malpractice Trial Report Death of 76-year-old woman from preventable medication error—30 times dose of real life case study involving medication error Lepirudin The plaintiff’s decedent was a 76-year-old woman who died on 11/24/10 from a hemorrhage. Her death occurred following a preventable medication error involving the drug Lepirudin. The patient was given over 30 times https://www.ismp.org/newsletters/acutecare/articles/20110310.asp too much medication which resulted in uncontrollable internal bleeding and her subsequent death. Her past medical history included cirrhosis with well preserved hepatocellular synthetic function. She also had Type 2 diabetes, hypertension and hypercholesterolemia, and a history of splenectomy for treatment of severe thrombocytopenia. In August, 2010, she suffered a fall which led to a right humeral fracture. Her fracture was to be managed conservatively. Following this http://www.lubinandmeyer.com/cases/medication-error.html injury, she remained hospitalized at various facilities due to anemia, acute renal failure, urinary tract infections, and an upper extremity blood clot. In November 2010, she was found to be suffering from Heparin induced thrombocytopenia (HIT). It was noted that in light of her HIT, immediate anticoagulation was necessary, and that Lepirudin would be administered. The order was for 0.1 mg/kg/hr in a premixed continuous infusion. It was to be titrated to a PTT level of 50-70. If the PTT was greater than 2.5 times the baseline, then the infusion was to be held for two hours and reinstituted at 50% of the original infusion dose. The PTT was then to be checked in 4 more hours. If the PTT was less than 1.5 times the baseline, that the infusion rate was to be increased by 20% and the PTT was to be rechecked. If in 4 hours the PTT was still subtherapeutic, the infusion was to be increased by another 20%. The maximum dose to be administered was 16.5 mg/hr. Lepirudin was started at 9:13 p.m. on 11/20/10. The initial dose was 7.2 mg/hr based on the patient’s weight of 72 kg. Over the next several days, the Lepirudin dose
Health Search databasePMCAll DatabasesAssemblyBioProjectBioSampleBioSystemsBooksClinVarCloneConserved DomainsdbGaPdbVarESTGeneGenomeGEO DataSetsGEO ProfilesGSSGTRHomoloGeneMedGenMeSHNCBI Web SiteNLM CatalogNucleotideOMIMPMCPopSetProbeProteinProtein ClustersPubChem BioAssayPubChem CompoundPubChem SubstancePubMedPubMed HealthSNPSRAStructureTaxonomyToolKitToolKitAllToolKitBookToolKitBookghUniGeneSearch http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4357082/ termSearch Advanced Journal list Help Journal ListPatient Saf Surgv.9; 2015PMC4357082 Patient Saf Surg. 2015; 9: 12. Published online 2015 Mar 13. doi: 10.1186/s13037-014-0047-0PMCID: PMC4357082Case http://journals.rcni.com/doi/pdfplus/10.7748/ns.29.15.37.e9520 report of a medication error by look-alike packaging: a classic surrogate marker of an unsafe systemJoerg Schnoor, Christina Rogalski, Roberto Frontini, Nils Engelmann, and medication error Christoph-Eckhardt HeydeDepartment of Anesthesia and Intensive Care Medicine, University Hospital Leipzig, Liebigstraße 20, 04103 Leipzig, Germany Office of Quality and Risk Management, University Hospital Leipzig, Liebigstraße 20, 04103 Leipzig, Germany Department of Anesthesiology, King’s College Hospital Clinics Abu Dhabi LLC, Abu Dhabi, UAE Shining Towers, Mubarak bin medication error case Mohammed St, Khalidiyah, PO Box 129923, Abu Dhabi, UAE Pharmacy, University Hospital Leipzig, Liebigstraße 20, 04103 Leipzig, Germany Department of Orthopedics, Traumatolgy and Plastic Surgery, University Hospital Leipzig, Liebigstraße 20, 04103 Leipzig, Germany Joerg Schnoor, Email: ed.gizpiel-inu.nizidem@roonhcS.greoJ.Contributor Information.Corresponding author.Author information ► Article notes ► Copyright and License information ►Received 2014 Jul 23; Accepted 2014 Dec 9.Copyright © Schnoor et al.; licensee BioMed Central. 2015This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.AbstractBackgroundThe acronym LASA (look-alike sound-alike) denotes the problem of confusing similar- looking and/or sounding drugs accidentally. The most common causes of medication error jeopardizing pa
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