Communication And Medication Error And Nurses
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Prevention Safety Resources Featured Writers Articles Case Studies Clinical Gems Clinical Presentations Disasters Averted Exclusive Interviews Polls Products Test Your Knowledge Videos Drug Lookup Tools Shop Login/Subscribe Home / Resources / Articles / Medication Errors: Is Communication the Key to Prevention? Medication Errors: Is Communication the Key to Prevention? June nurse medication error cases 14th, 2005 Share Facebook Twitter LinkedIn Do these sound all to familiar? A patient who was transferred from one hospital to another received a duplicate dose of insulin because the receiving nurse didn't know the medication had been given before transfer. The patient's medication history had not been provided to the receiving facility until several hours after the patient's arrival. Using the patient's handwritten list of medications taken at home, a physician misunderstood an entry for DESOGEN (ethinyl estradiol and desogestrel) and prescribed digoxin 0.25 mg daily. Later, a nurse discovered the error when she asked the patient why she was receiving digoxin. Shortly after admission, a patient became lightheaded and fell in the bathroom after a physician prescribed TOPROL XL (metoprolol extended-release) at a dose larger than she took at home. The patient required telemetry monitoring and hydration for 24 hours. A newly admitted patient with pulmonary hy
Home Food Drugs Medical Devices Radiation-Emitting Products Vaccines, Blood & Biologics Animal & Veterinary Cosmetics Tobacco Products Drugs Home Drugs Resources for You Information for Consumers (Drugs) Strategies to Reduce Medication Errors: Working medication error nursing journal to Improve Medication Safety Share Tweet Linkedin Pin it More sharing options Linkedin Pin it nursing medication error articles Email Print When Jacquelyn Ley shattered her elbow on the soccer field, her parents set out to find her the best care nursing medication error stories in Minneapolis. "We drove past five other hospitals to get to the one we wanted," says Carol Ley, M.D., an occupational health physician. Her husband, an orthopedic surgeon, made sure Jacquelyn got the right surgeon. After a http://www.diabetesincontrol.com/medication-errors-is-communication-the-key-to-prevention/ successful three-hour surgery to repair the broken bones, Jacquelyn, who was 9 at the time, received the pain medicine morphine through a pump and was hooked up to a heart monitor, breathing monitor, and blood oxygen monitor. Her recovery was going so well that doctors decided to turn off the morphine pump and to forgo regular checks of her vital signs.Carol Ley slept in her daughter's hospital room that night. When she woke up in http://www.fda.gov/Drugs/ResourcesForYou/Consumers/ucm143553.htm the middle of the night and checked on her, Jacquelyn was barely breathing. "I called her name, but she wouldn't respond," she says. "I shook her and called for help." The morphine pump hadn't been shut down, but had accidentally been turned up high. The narcotic flooded Jacquelyn's body. She survived the overdose, but it was a close call. "If three more hours had gone by, I don't think Jacquelyn would have survived," Ley says. "Fortunately, I woke up."Ley was pleased with the way the hospital handled the error. "They came right out and said the morphine pump was incorrectly programmed, they told me the steps they were going to take to make sure Jacquelyn was OK, and they also told me what they were going to do to make sure this kind of mistake won't happen again. And that's very important to me." The hospital began using pumps that are easier to use and revamped nurses' training. Ley believes there were many contributors to the error, including the fact that it was Labor Day weekend and there were staff shortages. "It goes to show that this can happen to anyone, anywhere," says Ley, who now chairs the board of the National Patient Safety Foundation.Multiple FactorsSince 1992, the Food and Drug Administration has received nearly 30,000 reports of medication errors. These are v
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