ctivities for to skill development and QI plan Analyzing a medication error case study Discussing root-causes in the case study NURS FPX 4020 Assessment 3: Improvement Plan In-Service Presentation
Activities for to skill development and QI plan
- Analyzing a medication error case study
- Discussing root-causes in the case study
- Discussing challenges faced by health care professionals
- Analyzing what could have averted the error
- Implementing EBP changes in the future
The patient has been admitted to a 20-bed medical unit for treatment of acute diverticulitis. The provider has ordered Ultram (Tramadol hydrochloride) 50 mg p.o. every 6 hours prn pain. The patient is requesting a pain medication, as it has been 8 hours since his last dose. The nurse selects the individually wrapped medication from the patient’s assigned medication drawer and scans the barcode to determine if it is the correct medication. The scanner is not working again. As she wants to administer the pain medication as soon as possible, she types in the Internal Entry Number (IEN) and the computer indicates the medication is Ultracet 37.5/325 mg but the package says Ultram 50 mg. The nurse calls the pharmacy and the pharmacist says there is only one number different between Ultram and Ultracet and, since the package says Ultram, to administer the medication because she must have typed in the wrong number. The nurse administers the medication, and within 30 minutes the patient shows signs of an allergic reaction. The nurse checks the record and determines the patient is allergic to acetaminophen. The patient is treated for the allergic reaction, and a medication incident form is completed. The nurse manager asks for a Root Cause Analysis (RCA) to be completed for the medication error.
References
- Abukhader, I., & Abukhader, K. (2020). Effect of medication safety education program on intensive care nurses’ knowledge regarding medication errors. Journal Of Biosciences And Medicines, 08(06), 135-147. https://doi.org/10.4236/jbm.2020.86013
- Hammoudi, B., Ismaile, S., & Abu Yahya, O. (2017). Factors associated with medication administration errors and why nurses fail to report them. Scandinavian Journal Of Caring Sciences, 32(3), 1038-1046. https://doi.org/10.1111/scs.12546