Assignment task:
Review the Human Factors Theory Case Study.
In March 2013, a coronial inquest was held into the death of a nursing home resident in Australia. The coroner found that the cause of death was related to an underlying disease and that no person contributed to his death. However, in the course of the inquest, it was established that a medication error had occurred during the hours preceding the resident's death, involving the subcutaneous administration of 25mg of morphine instead of 2.5mg.
The coronial report identified that the nurse involved was a new graduate, working her second shift as a registered nurse at the nursing home. The nurse had not undergone the requisite two days' orientation or 'buddying' required for new nursing home staff members. During the shift in question, the nurse was in charge, working with three extended care assistants (nursing assistants). There were 36 residents, of whom 18 were classified as 'high care' and nine as 'medium care'. The care of one resident required a significant amount of attention from the nurse, which involved ongoing interaction with other healthcare professionals, external to the organization. This resulted in time pressures with regard to meeting the nursing care needs of the other residents. While the nurse was occupied liaising with external healthcare professionals, the extended care assistants reminded the nurse several times that the resident, who subsequently became the subject of the coronial inquest, required morphine, which was overdue. All of the above constitute the latent factors that may have affected, to varying degrees, the active failure that occurred when the nurse administered the wrong morphine dose to the resident.
In error, the nurse administered 25mg instead of 2.5mg and discovered the mistake when she went to prepare the next dose of morphine. The nurse described in her affidavit the process of preparing the morphine: I went to the drug storage room at the facility and removed a package of morphine... I quickly looked at the packaging and incorrectly saw1mg/1mL, whereas the correct ampoule strength was 10mg/1mL. The medication order was for 2.5-5mg morphine sub/cut per four hours.
I drew up 25mg/2.5mL, as the correct packaging was for 10mg/1mL. I had never administered morphine before and, as previously mentioned, had not viewed the packaging and labeling of morphine ampoules. I was not familiar with the
standard dosage of morphine. I asked one of the co workers... who was with me at the time to check the dosage with me... (the extended care assistant) double-checked the dosage but did not notice my mistake either...' (Magistrates Court of TasmaniaCoronial Division 2013).
Q. What recommendations do you have in this situation?