The case history is based on actual medical negligence claims or medicolegal referrals; however certain facts have been omitted or changed by the author to ensure the anonymity of the parties involved.
Case Study: Medication Errors
Medication errors usually occur as a result of a breakdown in a system of health care delivery. Studies indicate that one third of adverse drug events are preventable. For every preventable adverse drug event, there is likely to be three times as many near misses.
Medication errors occur most frequently at the ordering and administration stages.
So what are the most common issues in relation to medication errors in hospitals?
- Wrong drug
- Poor response to treatment
- Similar names
- Wrong dose
- Staff fatigue
- Incorrect drug
- Stress
- Wrong patient
- Wrong concentration
- Wrong method of administration
- Look alike drug
- Verbal check
- Wrong time
Case Study
A 68-year old male patient had undergone an uneventful right coronary angioplasty. He required a removal of the sheath which was inserted into his femoral artery and vein. In order for the sheath to be removed, 100mcg of Fentanyl, 600mcg of Atropine and 15mls 1% of Lignocaine were to be administered. This medication was ordered by the RMO who was going off duty at 7pm.
She had written the drugs under "the Short Order", a telephone order treatment sheet and had also written the drugs under the "Pre-medication Orders" treatment sheet. All the drugs were drawn up by nursing staff.
Dr Clark came on night duty at 9pm and administered the Lignocaine, he did not order or sign the patient's medication chart. Nor did he check the vials of Fentanyl or Atropine and was not shown any syringes containing the Fentanyl or Atropine by the nursing staff. Dr Clark also failed to check the medication chart.
Dr Clark administered the Lignocaine to the patient's groin and he instructed the nurse to administer the Fentanyl and Atropine. He did not observe the nurse administer these drugs.
The two Registered nurses readily checked the doses and amount to be administered and this was performed. The patient was given 500mcg of Fentanyl intravenously by the nurse, not the 100mcg which was ordered.
The patient died and both Dr Clark's and the nurse's account of the conversation regarding the amount of Fentanyl to be administered, was at issue.
One Registered nurse stated to her colleague that Dr Clark had told her to "give all the dose of Fentanyl as a bolus dose". He disputed this. The medication chart stated 100mcg of Fentanyl to be administered and 600mcg of Atropine. Both Dr Clark and the nurse had differing accounts of the conversation regarding administering the Fentanyl. The nurse maintained that she verbally checked with Dr Clark if 500mcg was to be administered and he had confirmed that it was.
How could this outcome have been avoided?
All staff must be conversant and aware of the policies and procedures related to checking and administering medication. There must be consistent usage of medication charts in all hospitals. Always write legibly use protocols and checklists. Medication charts are to be regularly checked by a pharmacist. This reduces the errors and allows accurate interpretation of orders by all members of staff.
The medication charts are to reflect this practice i.e. the dose, the amount, the method, the administration must be clearly written and signed by the prescribing practitioner on the appropriate medication chart. It is essential that medications are always checked with a colleague before they are administered.
If a doctor is asked to verbally confirm the dosage or type of drug to be administered and you have not prescribed the drug you must check the treatment sheet first.
If a doctor or nurse is required to administer a drug they must check the treatment sheet with the patient and determine that the drug that has been drawn up or that is to be dispensed is the appropriate drug and amount to be administered. Always double check before administering any medication.
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The Medical Defence Association of Western Australia (Incorporated) trading as MDA National, ARBN 055 801 771. MDA National Insurance Pty Ltd ABN 56 058 271 417, AFS Licence No. 238073. Form No 906.2 March 09. Information in Student E-News is intended as a guide only and should not be taken as legal or clinical advice.
