Question

Pharmacology: A physician wrote a prescription for “.5 mg IM morphine for postoperative pain” for a 9-month-old infant. The unit secretary recorded the order in the MAR as “5 mg.” An inexperienced nurse followed the directions on the MAR without question and gave the baby 5 mg of IM morphine initially and another 5-mg dose 4 hours later. About 2 hours after the second dose, the baby stopped breathing and experienced respiratory arrest. If the physician had written “0.5 mg,” the unit secretary would probably not have had any misunderstanding of the intended amount, and the nurse would have administered the correct dose.

1. Although the initial error was not the nurse’s, what steps should he or she have taken to avoid this medication error?
2. What measures could the facility implement to curtail future medication errors?
3. Explain how using a standardized written measurement system would have prevented this adverse drug event.
4. What technology is available to help prevent errors and has it been successful?

Answer 1

Steps to be taken to avoid medication error includes
- Ensure the five rights of medication administration.
-double-check the drugs and dose and physician order
- Make physicians read back that medication orders whether correct or not.
-consider name alert sounds with the same name.
-Place zero in front of the decimal point to avoid an adverse outcome
-document everything by labeling with record
-store the medication properly
-Ensure medication administration policy, regulations, and guidelines before administering medication.
Medication error causes serious adverse problems. The facility should face challenges and implement to establish a culture of safety. health care teams should play an important role in making safety for patients. Health care facilities should work collaboratively to avoid medication errors. it should measure the target to process improvement to avoid errors and outcomes.
A high frequency of medical error causes patient harm and cost. using technology innovation by personal health record prevent medication error. it can be implemented through economic incentives and government policies. standardization of EHR implementation IT system provides safety and reduces medicine error. personal health record engagement through computer-based tools make people access and coordinate the information provided by the physician. PHR medication information by physician provide an accurate report and decision support tools. it makes potential effectiveness to reduce medication error.
Technology reduces medication error by electronic prescribing and the medicine administration system reduces medication error. computerized physician order entry, automated dispensing, electronic medication reconciliation, using barcode and PHR are the strategies that will prevent drug error. it must be addressed by implementing economic incentives and government policies.