Question

Based on the results of below given case study, please explain following points;

Mrs. Patel, an Indian-speaking mom, took her son to the doctor for a cough and he was diagnosed with asthma. He was given a prescription for the medication. The prescription read, “Take 2 ml by mouth twice daily.” The doctor asked his staff to give Mrs. Patel the instructions in Hindi language. The mother saw the number “2” on the bottle and gave her son two teaspoons for each dose. After two doses, her son felt worse, so Mrs. Patel took him back to the doctor. The staff had never given Mrs. Patel the instructions in Hindi language, resulting in the patient having received five times the dose each time he received the medication. This could have been fatal.

1. Why do you think Mrs. Patel’s son’s condition became worse?

2. How could you improve the information the patient was given?

3. How could you improve communication between providers and clinical staff?

4. What changes can be made in your organization to prevent this from happening?

Answer 1

Answer: The client's condition became worse because the client got more than the double dose as the prescribed dose. The physician has prescribed 2ml twice a day, but the client was administered 2 teaspoon. :

In 1 teaspoon there is 4.929 mL

So, in 2 teaspoon it will be 2× 4.929 = 9.85 mL. This was given to the client twice a day.

Hence this is the more than the double dose that has been prescribed to the patient. Hence, the medication error causes this worse condition of the client.