Medication Error, a Preventable Event Essay

In the same document, National Academies informs the readers these numbers may be an understatement due to insufficient data. While in nursing school, I have realized the importance of dosage calculations, and hospital protocol. Most rationales to these rules are for the safety of the clients, which is why one must learn partially in theory and the rest through practice and repetition. Research is done in evidence based practice which provides confirmation to the ways procedures are carried out. As a nurse we should never get careless or sloppy with the work we do to assist our clients to health.The patients we care for are of great importance and responsibly to us as the caretaker.

With this in mind, I would like to show what carelessness ND oversight can result in. Ursula Samson was an 80 year old mother of four. She developed pneumonia and checked in to Good Hope Hospital, Birmingham to be treated in the intensive care unit. While being treated for low serum potassium levels her nurse Mrs.. Lisa Sparrow, URN entered an incorrect time frame on the infusion pump giving her a fatal amount of potassium chloride in one hour instead of over five hours.

I will walk through this incident and illustrate the areas in which checkpoints that are set up for nurses should have been utilized to avoid this unfortunate event. Pneumonia is an inflammation of the lung. The cause of the disorder is all dependent on the type of microorganisms found in the lungs and how the microorganisms were acquired: Community-acquired pneumonia (CAP), Pneumatics pneumonia (PC) for the pneumonia in the miscomprehended host, or aspiration pneumonia just to name a few. Usually this disorder can be treated at home unless there are factors to increase the patient’s risk.If there is a preexisting medication condition, if the symptoms are severe enough, if the person has not improved after taking antibiotics or if the patient is extremely young or older than 65 years old they will most likely be taken to a hospital. The goal of treatment is to cure the infection and prevent complications. Some of the complications include changes in the serum electrolyte levels in the body from the antibiotic use such as potassium.

Potassium is a major intracellular electrolyte. 98% of the potassium is inside of the cells, influencing both skeletal and cardiac muscle activities.The normal serum potassium concentration ranges from 3.

5 to 5 meg/L (3. 5 to 5 mol/L) (Hinkle& Achiever, 2014). A decrease in potassium levels can be caused by excessive alcohol use, prescription diuretic or antibiotic use. Symptoms of low potassium may include fatigue, muscle cramps, and abnormal heart rhythms also known as arrhythmias. Arrhythmias are more worrisome when the patient has an underlying heart disease. The best action to take with this hypoglycemia is to give administer potassium chloride via intramuscular replacement therapy.Each health care facility has its own policy for the administration of potassium, which must be consulted.

Some of which include, the nurse must be sure to monitor serum potassium levels, monitor the electrocardiograph, and check the IV site for signs of irritation or phlebitis (According to Intuitionist. Org, 2011). According to Good Hope Hospital’s policy on administering potassium chloride to a patient, two nurses were supposed to remove, check and administer the drug together. Similar to how I’ve seen in Plantation General Registered Nurses needing a cosigner for insulin administration.

These are one Of the first issues I’ve noticed with this situation. The second nurse was supposed to be Mrs.. Susan Smith, URN. Nurse Sparrow told the inquest she had not expected Nurse Smith to watch her give the potassium as ‘no-one ever did’ (Daily Mail, 201 1).

The second issue have noticed was, though investigation into the matter states there were no issues tit it, was the infusion pump. Nurse Sparrow accidentally pumped Mrs.. Samson with 50 ml of Potassium Chloride over half an hour instead of over five hours. Othello ml per hour button was pressed instead of 100 ml per hour.The technology of a fusion pump enables the programming and calculating of doses as well as delivery rates easier to be set. While smart pump technology helps reduce medication errors and prevent patient injury, it is not intended to replace clinical practices, institutional policies, and vigilant patient monitoring (Cummings & McGowan, 2015). Errors and patient harm can be irately reduced if features from the infusion pump were used properly; provided the smart pumps offer additional safety checks that may make administering IV medication safer.

While using this technology nurses may become careless and begin forgoing the “five rights” of medication administration: the right patient, right drug right dose, right route, and right time. According to this situation two of the five rights were not checked. This mistake could have been caught if the second nurse double checked as is needed with high risk infusions. Following recommendations from the Fad’s infusion pump website may help prevent future errors such as this: Before changing or starting an infusion setting be sure to double check the pump is programmed correctly.When infusing high-risk medications, be sure to have infusion pump setting double checked by an appropriate party according to your facility’s policy. The nurse must be sure to not rely solely on the infusion pump to identify their miscalculations.

Alerts and cautions from the infusion pump should be investigated properly and thoroughly. Finally, one that feel is important is to be sure you’re properly educated to manage all infusion pumps used in your unit. To prevent future incidences such as these the FDA has suggested a few changes. Some of which you have seen before: Nurse sometimes have difficulty reading a doctor’s handwriting.

To prevent miscommunication between doctors and nurses hospitals are increasing in computerized systems that can be utilizing by doctors as well as nurses. Drugs that are look-alike sound alike are a great source of concern; such as how Micas which is given to inhibit fibrously with Macro which is a lipid- regulating agent. So the FDA reviews the drug names that are requested to be used by company brand names and reject about one-third of the names that he companies propose. In conclusion, medication errors are serious occurrences that should be thought about constantly to prevent such recurrences.Rushing is never necessary and steps should not be skipped because other people are too busy.

Specific medications should be double checked to be sure the proper amount and frequency is being set. The five right always be checked when administering medication (the right patient, right drug, right dose, right route, and right time) as well as checking the pump before changes are made to a prescription or new medication is being set up, and the patient should be monitored after the medication is given for possible adverse effects.