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Today, patient safety necessitates continuous changes supported by evidence to eradicate flaws in the healthcare system. For this paper, the issue that the root-cause analysis will explore is the wrong medication dosage. The event occurred in the ward of a hospital where I worked in the past, where a nurse administered the wrong insulin dose. This paper analyzes the root cause of the issue, evidence-based strategies to address the issue, an evidence-based safety improvement plan for safe medication administration, and organizational resources that can be used to improve a plan for safe medication administration.
The issue arose when a nurse administered 200 units of Lantus to a patient just before the end of her shift. It was detected by a nurse on the next shift when doing regular blood sugar checks on patients on antidiabetic medications. The nurse found the patient’s blood sugar levels to be 49 mg/dL. In this case, the patient was affected as she ended up becoming hypoglycemic. The hypoglycemia was solved by administering D50 to the patient. After talking to the nurse who had helped the patient with the insulin, the nurse said she had helped 200 units of Lantus insulin. However, it was later discovered that she was supposed to assist 20 units instead of 200. The nurse also stated having been interrupted by two patients while administering the medication. The pharmacist had misread the order and transcribed it onto the medication administration record as “200 units Lantus every 24 hours” instead of “20 units Lantus every 24 hours”. However, when the handwritten order from the physician was checked, it was found that the physician’s handwriting was not clear, and one could quickly think he had written 200 rather than 20. The pharmacist was asked if he had asked the physician about this for clarification, and in response, he said the physician had neither indicated his name nor his phone number on the medical order. Therefore, in this case, the environmental factor that might have contributed to the error was an interruption, as the nurse was interrupted by patients, thus failing to realize that the dose she was administering was too high. There was also a human error of illegible handwriting from the physician since one could not easily conclude that he had written 20 and not 200.
Several evidence-based strategies can be used to solve medication errors related to administering the wrong dose of a medication. Interruptions have been cited as one of the significant causes of medication errors. In a study by Johnson et al. (2019), where there were interruptions in 99% of medical events, it was found that a clinical error was reported in 3.6% of the events. The most common medication error caused by interruptions is the wrong dose of medication. As shown by Kellogg et al. (2021), of all the medication errors that interruptions can cause, the wrong dose is the most common, accounting for 14.4% of all medication errors. Illegible handwriting is also a common cause of medication errors. Bhutada (2020) found that illegible handwriting is linked to 44.1% of transcription errors. The transcription errors are mainly related to the name, dose, and frequency of administration of drugs.
Medication errors caused by interruptions can be minimized by having separate rooms for medication preparation and administration. Huckels-Baumgart & Manser (2021) showed that having a separate room for medication preparation and administration reduces the rate of medication errors from 1.3 to 0.9 per day. Another strategy could involve using ‘do not interrupt’ vests. This can alert patients and other healthcare professionals that nurses are engaged in a meaningful activity and should not be interrupted. Schutijser et al. (2019) found this intervention effectively reduces medication errors.
Other strategies to mitigate the issue of administration of wrong doses of medications can be based on handling the problem of illegible handwriting. Computerized pharmacy order entry (CPOE) prevents errors caused by illegible handwriting from physician orders. It reduces medications that would have been caused by poorly handwritten names of drugs, dosages, frequencies, and abbreviations. In addition, using CPOE can help facilitate communication between healthcare professionals. This is achieved using a system where all healthcare professionals can put their names and contact information on medical orders (Moudgil et al., 2021). The presence of contact information on medical orders can ma
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