Question

Critical Thinking: Medication Error Prevention Date: Name: Precise measurement of doses in I ml, and 3ml syringes. La the following situation an incornect dose was administered because the computed volume was not rounded properly. ERROR: Rounding more decimal places than are necessary and selesting the wrong size syringe SCENARIO: A newborm infant was to receive gentamycin sulfate 7.5 mg. intravenously every 24 hours. Using a 2 ml vial supplied with 10mg'ml of gentamycin, the nurse calculated the volume needed as 0.73mL. This volume may be delivered precisely using a 1 mL syringe. No rounding is needed. In this case, the nurse rounded 0.75 to the whole number 1 and sdministered l ml of medication using a 3ml syringe. He infant was given 0.25 mL or 2.5mg additional medication. If the nurse continued to care for this infant on subsequent days, the error might continue with serious overdosage implications. 1. If the nurse would have cared for this infant, continuing with the wrong dosage bow much additional medication would this infant have received in 7 days? 2. What are at least 3 serious outoomes had this medication error continued for 7 days? 3. Why are blood levels ordered during the administration of gentamycin? 4. What would have been your action(s) had you discovered this medication error? 5. How could this medication error been prevented? A. Cormpare the calibration of a l mL syringe with a 3 ml syringse B Is gentamycin considered a high alert drug? Reviewed 9/1

Answer 1

1)Given

Medication :Gentamycin sulphate

Ordered dose:7.5mg/day

2ml ampoule =20mg/ml ,so 1ml=10mg

The nurse rounded of and administered  1ml that is 2.5mg in excess in a day

So for 7 days=17.5mg (7×2.5) will be administered

2)The major adverse effects of the drug if given continuously for 7 days are

• Ototoxicity
• Nephrotoxicity
• Neurotoxocity

3)The following blood test are necessary before administration of gentamycin are

• Renal function test especially Sr.creatinine
• Sr.Aminoglycosid

4)As this is a medication error the following actions are necessary

• Monitor the child for any toxicity or adverse effects
• Inform this to the incharge,nursing supervisor
• An incident report to be prepared
• The concerned pediatrician has to be informed and treatment should be followed up
• The nurse has to to be warned and taken for regular nursing education programs to avoid any types of error in future