Reference no: EM132928975 , Length: 650 Words

NUR 2390 Pharmacology - Implications and Practice - Molloy College

Analysis of a Medication Error or "Root Cause Analysis"

Instructions

1. Search in reputable nursing journals and news sources for information on one of the following:

1. South Nassau Communities Hospital Insulin Pen Error: March 11, 2014
2. Baby Gianni Vargas: Potassium Overdose at Stony Brook University Medical Center February 2002
3. Calcium chloi ide overdose at Children's Hospital Regional Medical Center in Seattle-September 30, 2010.
4. Heparin overdose at Cedars-Sinai Medical Center in Los Angeles involving Dennis Quaid's twin infants November, 2007.
5. Vecuronium administered instead of Versed - Tennessee nurse 2017 6 Excessive amounts of Levophed given - Vibra Hospital Sacramento 2014
6. Any medication error of your choice other than the above that made national headlines and was discussed in one of more nursing journals

2. Be sure to include links to all materials you use in your reference section.

3. Look up the medication or medications involved in a drug reference so you know what they are for, the usual dose, etc. Include that in your paper.

4. Content: In your paper, describe the event as thoroughly as possible:

a. Introduction: Describe the current problem with medication errors.include the 5 rights plus 5 and 3 checks that nurses should do to reduce the risk of medication errors. Be sure to support your information with a professional source (journal article).

b. Describe the situation: Describe m your own words what happened. Be as specific and detailed as possible. Describe the type of unit, and any cultural or work-flow issues that may have been present. State the original provider's order, how it was dispensed, who administered it and how. What was the problem? Describe the patient's response, and what harm was done If no harm was done, describe what harm COULD have happened? Cite your drug reference and other sources.

c. Analyze the error: Identify where the error occurred and with whom. Was it prescribed incorrectly? Dispensed incorrectly? Administered incorrectly? Or was there a known drug interaction or allergy that could have been anticipated?

d. Were there any special circumstances involved? Was there an emergency at the time? Was there short staffing? Was someone distracted?

4. Analysis: Using all of the information above, explain WHY the error occurred, WHY it got as far as it did, and WHAT can be done to stop it.
a. What circumstances contributed to this error?
b. Where in this situation could the error have been stopped? How? What would need to have happened for the error to be prevented?
c. Where in this particular situation would a nurse have been able to intervene to stop a potential error from occurring? (It may be more than one place.)

5. Summary: Briefly summarize the "take away" message. What can nurses learn from this error so that it doesn't happen again?

6. APA Style:
a. The paper should be typed, double-spaced, with a cover sheet and reference page in APA format. (Be sure to reference the original article, the drug reference, and any other sources used.)