Medication Error Case Scenario
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2011 issue Problem: When you think of “wrong patient” medication errors in inpatient settings, the most common scenario that comes to mind is a nurse walking into a patient’s room and administering medications intended for one patient medication error scenarios to another patient—often a roommate. Perhaps the patient had switched hospital beds with his roommate medication error case report to be closer to the window, or he was sitting on the edge of his roommate’s empty bed. Maybe the nurse had
Real Life Case Study Involving Medication Error
verified 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
Medication Errors Case Reports
the nurse simply forgot to complete the verification process. In any case, one fundamental cause of these errors is a 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 cases of medication errors by nurses 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 administered to the son, or vice versa, even if the nurse had properly identified the patients using name and medical record number. Prescribing Order entry error. A dehydrated lung cancer patient was admitted to the emergency department for IV hydration. Another patient from a motor vehicle accident (MVA) was awaiting intubation and transfer to a local trauma center. The same physician was caring for both patients. The physician gave verbal orders for vecuronium and midazolam for the MVA patient, but he inadvertently entered the medication orders electronically into the cancer patient’s record. The nurse caring for the cancer patient went on break, and a covering nurs
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Nursing Medication Error Stories
My Account|My Account or Logout Search form Search Patient Care OnlineAll a case of medication error conversion factors in clinical calculations answers Sites Topics:Atrial Fibrillation|Cardiovascular Diseases|COPD|Men's Health|Diabetes Type 2|Pain|HIV AIDS|Nervous System Diseases|Obesity|Respiratory Diseases|Browse All TopicsAll TopicsAtrial FibrillationCardiovascular DiseasesCOPDMen's HealthDiabetes a case of medication error by brahmadeo dewprashad answers Type 2PainHIV AIDSNervous System DiseasesObesityRespiratory Diseases ubmslateCL-logo-ubm ≡ Main menuHomeTopicsBuyer's GuideJournal MAIN MENU Home Topics Dermatology Cardiovascular Diabetes GI HIV/AIDS Conferences Quizzes Photoclinic Image IQ Pediatrics Medication Errors https://www.ismp.org/newsletters/acutecare/articles/20110310.asp in Adults—Case #1: Warfarin Medication Errors in Adults—Case #1: Warfarin July 29, 2013 | Nervous System Diseases, Atrial Fibrillation, InfectionBy Bradley M. Wright, PharmD, BCPS Medication errors may occur at any point in the health care system. Obtaining a true estimate of the number of errors is difficult, but preventable medication errors are known to http://www.patientcareonline.com/nervous-system-diseases/medication-errors-adults%E2%80%94case-1-warfarin increase patient harm and total health care costs.1 This series will highlight some of the most important errors and address methods to decrease the risk of them occurring. Drug #1: WarfarinA 52-year-old male taking warfarin daily for prevention of stroke with atrial fibrillation develops a skin infection and visits the local urgent care center on a weekend for evaluation and treatment. The patient receives a diagnosis of cellulitis and a prescription for Bactrim®, trimethoprim/sulfamethoxazole (TMP/SMX), to be taken twice daily. The drug is dispensed by a pharmacy near the urgent care center, not the patient’s usual pharmacy. Several days later, the patient is admitted to the hospital with an acute bleed and an elevated international normalized ratio (INR).What is the problem in this scenario?DiscussionWarfarin remains one of the most frequently prescribed medications in the United States, and it appears on the Institute for Safe Medication Practices list of high-alert medications because overanticoagulation or underanticoagulation has important consequences.2 In addition, medication errors that lead to adverse
others: Purchase online access. FREE PREVIEW. Purchase online access to read the full version of this article. Am Fam Physician. 2001 Mar 1;63(5):985-988.Case ScenarioMy patient, an 82-year-old man who had smoked cigarettes for 60 years, was admitted to the hospital for exacerbation of http://www.aafp.org/afp/2001/0301/p985.html chronic obstructive pulmonary disease (COPD). A chest radiograph was obtained the day of his discharge, and a small density was noted by the radiologist. The recommendation was to follow up with a computed tomographic (CT) scan.One month later, the patient came to our clinic for an appointment. It was a typical hectic day, and I was fatigued because I was on obstetric service and post-call. I readily recognized my patient's medication error face but could not remember all of his medications and was unsure if he had been admitted the previous month for congestive heart failure or COPD. My patient couldn't remember either. The discharge summary and radiology reports from the hospital were not at the clinic. Frustrated, I paged the senior resident from the previous month. Thankfully, from the patient's name alone he recalled the man's medications and the chief diagnosis. With of medication error this information, I was satisfied that I had put together the pieces.I presented the patient to the attending physician and indicated that I remembered the important details of the patient's hospitalization. Because I thought I knew the details, I did not subsequently have the hospital reports sent to me. Meanwhile, I came to know the patient and his son very well. I followed up frequently on the telephone and in the clinic as his COPD worsened, and I arranged for home care needs.Ten months later, the patient signed in for a walk-in visit following an episode of hemoptysis. A chest radiograph was obtained, and a large lesion was seen in the lung. A follow-up CT showed multiple lesions throughout the lung. I promptly referred the patient to pulmonary and oncology subspecialists. At this point, I still did not remember that a lesion had been seen on a chest radiograph the previous year. To be thorough, I decided to go to the hospital to review the patient's old films and hospital chart. At this point, I read the note I had written just before the patient's discharge, in which I had commented on the radiology report and stated that an out-patient CT scan would be obtained. I now remembered