Question

Case Study – Medication Error

You are a physician making rounds on your patients when you arrive at Mrs. Buckman’s room. She is an elderly lady in her late 70’s who recently had colon surgery. She is also the wife of prominent physician at the hospital. She has been known to be somewhat confrontational with the nursing staff. However, today she states she was just given a shot of insulin to cover her elevated blood sugar and the amount of insulin did not seem to be the usual amount. Even though Mrs. Buckman often complains, you are somewhat concerned about this observation and decide that it would be best to check on this.

You ask the charge nurse to review the dose of insulin given. She, in turn, finds Mrs. Buckman’s nurse, who states that, as ordered she had given the patient 80 units of insulin. You immediately become quite alarmed, as this is extraordinarily large dosage. You make sure that the patient is given a large amount of glucose supplement and that her blood sugar is monitored every 15 minutes for the next two hours. To follow up, you also review the chart and note an order from the house physician to give Mrs. Buckman 8.0 units of insulin. You can readily see how this could easily appear to be 80 units.

You meet with the charge nurse, the nursing supervisor, the Director of Nursing (DON), and the treating nurse to determine what can be done to prevent this type of error in the future.

What are the management issues that need to be addressed in the case?

Should the nurse have questioned giving this large amount of insulin without checking with the doctor?

Should the pharmacist have questioned the dosage?

Please give the following.

Background Statement

• Major Problems and Secondary Issues

• Your Role

• Organizational Strengths and Weakness

• Alternatives and Recommended Solutions

• Evaluation

Answer 1

The key management issue here is the safety of patient. This has to be strictly followed by all healthcare professionals to prevent medical errors especially medication error during their practice.

The inadequacies in staff training in regards to medication administration and precautions can cause these types of errors.

The nurse must have questioned the large dose of insulin before administration of the medication with the concerned provider,double checked the order,go through the blood glucose and indulge chart before administering to prevent the medication error.

The pharmacist has indirect role by just supplying the requested medication and not its administration. As a safety measure the pharmacist can raise the concern for the large dose.

Background statement:Medication error

Major problems and secondary issues

• Very high risk for hypoglycemia
• Potential risk for complications associated with low sugar
• Interruption in the wound healing process due to low glucose level after colon surgery

Role

• Supervise the medication administration
• Education programs
• Action against the staff
• Making sure adequate first aid or done to prevent complications

Organizational strength and weakness

• Making strict policies, protocols for insulin administration
• Inadequate follow up ,wrong interpretation can be some weakness

Alternative and recommended solutions

• Treating the patient until blood glucose are stabilized
• Regular and periodic staff training
• Making use of electronic health records for documentation

Evaluation

There should be an reduce rate of medication error and improved quality of care