Question

CASE 24 Medication Error Dale Buchbinder

You are a physician making rounds on your patients when you arrive at Mrs. Buckman’s room. She’s an elderly lady in her late 70s who recently had colon surgery. She is also the wife of a 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 an 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, and the treating nurse to determine what can be done to prevent this type of error in the future.

ANSWER THESE QUESTIONS:

• Background Statement
• Major Problems and Secondary Issues
• Your Role
• Organizational Strengths and Weakness
• Alternatives and Recommended Solutions
• Evaluation

Answer 1

Q. No. 1. Answer :

Back ground of the statement :

Medication error :

Mrs. Buckmans, she is 70 years old, she has elevated blood sugars, to treat that the nurse has administered, insulin that is 80 units, but doctor has advised to give 8.0 units.

So the nurse has given over dose for her like instead of 8.0 she was given 80 units, so it is a medication error.

This is the back ground of the study.

Q. No. 2. Answer :

Major problems and secondary issues :

* the client may go to severe sudden hypoglycemia state.

* hypoglycemic shack may come then it leads to coma.

* so adverse effects is one of the major problem due to medication error.

Secondary issues :

* problems arises due to medication error.

* conflicts may come in between client attenders and hospital staff due to wrong administration.

* there will be a negative mark to the staff and hospital, due to any death in that hospital.

Q. No. 3. Answer :

My role to prevent medication error :

* first we need to take physician decision on medication administration.

* prescription should be taken.

* if not understand the writing once again ask and clarify the dose.

* next identify the patient and there problem, here patient is having high glucose levels.

* so, next prepare and take the medication dose correctly, and once again conform with the senior staff and give dose to the client.

* absorve for side effects.

* and record and report it.

* here already given 80 units.

* so there a chance to hypoglycemia so check the sugar levels and administer dextrose according to doctor prescription.

* continueously monitor the client to prevent complications.

Q. No. 4. Answer :

Organizational strengths :

* skilled nursing care providers.

* good communication skills among all staff who are involved in hospital like mainly between nurse and the doctor while giving medications to the clients.

* following all rights of drugs administration.

If above all are good the organization have strength to provide care.

Weakness :

* poor communication skills.

* poor quality care

* improper maintainance of rules and regulations of hospital.