Risk Management and Patient Safety Essay
Risk Management and Patient Safety Essay
Medication Error Prevention and Action Plan
According to the scenario provided, there was a medication error event. The error in this case was due to an act of omission due to the deletion of a drug that was previously used before admission of patient Diane. Medication errors can lead to patient harm, cause irreversible physical damage and even death as in the case of patient Diane. The patient was on Lasix, an antidiuretic used for the treatment of high blood pressure and fluid overload associated with heart failure. As a result of the nurse failing to erase the old MAR after recording a new one, the diuretics were stopped. The side effects of stopping heart failure mediation include high blood pressure, edema, tachycardia, pulmonary edema and tachypnea (Rohde et al., 2019). The patient ultimately suffered a cardiac arrest and died.
To prevent such errors in the future, nurses on duty should recheck and countercheck medication orders before endorsement (Kim & Lee, 2020 Risk Management and Patient Safety Essay). Ideally, the nurse on call should ensure the removal of old MARs to avoid medication errors. Nurses should also ensure that when handing patients over to the incoming nurse on duty, the medication administration records are properly reviewed to avoid errors. Nurses should ensure that they adhere to the five rights of medication administration: right medication, right dose, right route, right time and right patient. Risk Management and Patient Safety Essay
Elderly patients usually use different medications and tend to change medications frequently, therefore making it easier for nurses to make medication errors. During admission, it is imperative that nurses check patient medication histories for completeness and accuracy. Also, proper documentation would go a long way in minimizing confusion and errors that may arise when administering medication. For nurses to implement these prevention measures, some form of learning must take place (Johnson et al., 2018). Learning theories will therefore be implemented in developing these prevention measures. A behavioral-cognitive knowledge-based education intervention can be used to decrease medication transcription errors. Risk Management and Patient Safety Essay
Risk Management and Patient Safety Essay References
Johnson, M., Levett-Jones, T., Langdon, R., Weidemann, G., Manias, E., & Everett, B. (2018). A qualitative study of nurses’ perceptions of a behavioural strategies e-learning program to reduce interruptions during medication administration. Nurse Education Today, 69, 41-47. https://doi.org/10.1016/j.nedt.2018.06.028
Kim, K., & Lee, I. (2020). Medication error encouragement training: A quasi-experimental study. Nurse Education Today, 84, 104250. https://doi.org/10.1016/j.nedt.2019.104250
Rohde, L. E., Rover, M. M., Figueiredo Neto, J. A., Danzmann, L. C., Bertoldi, E. G., Simões, M. V., Silvestre, O. M., Ribeiro, A., Moura, L. Z., Beck-da-Silva, L., Prado, D., Sant’Anna, R. T., Bridi, L. H., Zimerman, A., Raupp da Rosa, P., & Biolo, A. (2019). Short-term diuretic withdrawal in stable outpatients with mild heart failure and no fluid retention receiving optimal therapy: a double-blind, multicentre, randomized trial. European Heart Journal, 40(44), 3605–3612. https://doi.org/10.1093/eurheartj/ehz554
Risk Management and Patient Safety Essay Instructions
Please review the case scenario and answer the questions below.
Diane was an 80-year-old resident who was returning to the nursing home from the hospital following a left hip fracture on Friday evening. She has a history of congestive heart failure with frequent exacerbations. Her hospital discharge medication list was different than the prior medication list at the nursing home, specifically relating to her Lasix prescription. Diane was already taking Lasix at the nursing home before her hip fracture.
All of her medication orders were transcribed by hand onto a new medication administration record (MAR). The old MAR, prior to the hospital stay, was not removed. The nurse checked Diane\’s new orders and wrote \”repeat\” next to the new Lasix order and yellowed out the line. She was interrupted and was not able to finish reviewing the orders so she asked another nurse to review it for her. The second nurse reviewed the order and saw that the old MAR was still there. She removed the old MAR and finished reviewing the new MAR. Risk Management and Patient Safety Essay
On Sunday, the medication nurse passed meds for Diane, as she had done for the past three days. She saw the yellowed line through the Lasix order and thought that the medication had been discontinued. She sent the medication back to pharmacy. Pharmacy picked up the medication on Monday. On Monday, it was noted that Diane weighed three pounds more since being discharged from the hospital. The nurse recorded the weight and placed a call to the physician, who failed to respond. At 2:00 a.m. Tuesday morning, Diane began to have difficulty breathing.
Assessment findings included +4 pitting edema, a BP of 190/110, a HR of 120, and respirations at 28. Crackles were heard through her lungs. The on-call physician was consulted and an order was placed to transfer Diane back to the hospital. She went into cardiac arrest while waiting for the ambulance and was not able to be resuscitated. Risk Management and Patient Safety Essay
Provide your risk analysis for this event. Develop an action plan for the prevention of events like this one in the future. Which theory or model would you apply in developing your action plan?