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Case Study Scenario 1: patient Safety / medication administration A nurse is preparing medication for a...

Case Study Scenario 1: patient Safety / medication administration

A nurse is preparing medication for a patient. When checking the medication against the medication orders in the electronic health record against the drug found in the patient’s medication compartment in the dispensing cart, the notes that hydroxyzine was ordered for the patient but hydralazine has been dispensed from the pharmacy.

What should the nurse do ?

Is this a medication error?

If so, what NCC MERP category of medication error is it?

How could this mistake have been averted?   

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Answer #1

What nurse should do?

1. First nurse make confirmation of physician order on drugs

2. Check the drug independent in pharmacy

3. Find out where the medicine is missing

4. Take steps fast to get medicine

2. Is this a medication error?

Yes.

Rational:

Physician gave order but the drug is independent from pharmacy but its not available on dispensing cart, so its a medication error on nonavailability.

NCC MERP:

Category B:

Error occurred but does not reach the patient. That error on omission.

How to avoid?

1. Follow all rights before giving medication

2. Make multiple verification on medication chart

3. Improve communication

4. Incorporate technology

5. Create culture of safety.

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