Problem
A charge nurse received a phone call from the pharmacist informing her that she had recognized that pharmacy had sent the wrong medication dose to the floor with the pharmacy tech. They had mistakenly sent 10mg tabs of morphine rather than 5 mg tabs. She was confused because she had done the medication check at the Pyxis machine with the pharmacy tech and she had already pulled that medication to give to one of her patients. She hurriedly went to the Pyxis to see if this was true and she discovered that there were 10mg tabs in the 5mg tab drawer along with some 5mg tabs. Thinking back, she had pulled 2 tabs out to give her patient and she was in a hurry so she scanned one of the pills two times rather than scanning each pill. She went to the trash can in the patient's room to find an empty 5 mg pill wrapper and an empty 10 mg pill wrapper. Rather than giving the patient 10mg of morphine, she had mistakenly given 15mg morphine to the patient. Her patient was more sedated than normal, she proceeded to get vitals immediately to discover the patient's respiratory rate was 9 and the oxygen saturation was 82%. She immediately called an RRT and the patient was administer Narcan and recovered from the overdose of morphine.
After reading this story, tell me how this situation could have been avoided and how you can apply the concept of the Swiss cheese model to your practice as a student and as a future nurse.