Assignment: Medication Error Case Study
Overview:
A medication error refers to any preventable event that may lead to inappropriate medication use or patient harm. These errors can occur at any stage of the medication use process, from prescription and dispensing to administration and monitoring. Medication errors encompass a wide range of mistakes, including incorrect dosage, drug interactions, administration route errors, and prescription of the wrong medication.
This assignment is to enhance your understanding of the critical role that informatics plays in healthcare, specifically in the context of medication management. Through the examination of a medication error, you will develop a deeper appreciation for the impact of information systems on patient safety, quality of care, and overall healthcare outcomes.
Instructions:
You will analyze a medication error case study using pharmacology and informatics materials to analyze, identify, and propose solutions to decrease the risk of medication errors. The case you will review can be found within the Medication Error Case Study document as found as a resource within the assignment in Canvas.
For this paper, after identifying and describing the medication errors in the case study, you will research and identify the factors contributing to the medication errors. Based on these findings, you will identify improvements to be made and explain how the use of informatics technology can eliminate or decrease the risk of the medication errors.
You will write a paper at least 1,250 words in length in current APA format on your analysis. The title page and the references do not count towards the 1,250-word count requirement. Be sure to include all of the following within your paper:
- Identify and describe at least 2 the medication errors from the Case Study. Need Assignment Help?
- Identify and describe at least 3 factors that contributed to the medication errors.
- Based on the findings, identify improvements to be made and explain how the use of informatics technologies (minimum of 2) could have eliminated or decreased the risk of the medication errors.
The paper must include at least 5 references (scholarly articles published within the last five years) in addition to the course textbooks and the Bible. Each reference must have at least one citation in APA format.
Note: Your assignment will be checked for originality via the Turnitin plagiarism tool.
Medication Error Case Study
The incident took place at General Hospital, a 500-bed tertiary care facility, where the patient, Mr. Smith, a 65-year-old male, was admitted for elective surgery to address a chronic orthopedic issue. Mr. Smith has a history of hypertension and diabetes, managed with a combination of antihypertensive and antidiabetic medications.
Mr. Smith was admitted to the hospital, and the nurse documented the patient's home medications, including lisinopril (an ACE inhibitor) for hypertension and metformin for diabetes in the electronic health record system (EMR).
Mr. Smith underwent preoperative assessments, and the provider prescribed various medications to be administered preoperatively, including a prophylactic antibiotic, Amoxicillin 2 grams IV, once and the pain management drug, Oxycodone 5 mg PO q4h, for pain. These medications were entered into the hospital's EMR. However, the provider did not complete the medication reconciliation process; thus, the lisinopril 10 mg PO per day and metformin 500 mg PO per day home medications were not included in the active list of medications. The pharmacy, unaware of the missing medications, dispensed the prescribed antibiotic and pain management drug.
The nursing staff received medication orders for prophylactic antibiotics and pain management. However, the omission of lisinopril and metformin from the orders went unnoticed. The nurse administered the scheduled medications without cross-referencing with the patient's pre- admission medications.
Postoperatively, Mr. Smith's blood pressure began to rise, and his blood glucose levels were elevated. The nursing staff, recognizing the issue, investigated the patient's medication history and discovered the oversight. The provider was contacted and ordered lisinopril 10 mg PO per day and metformin 500 mg PO per day in the EMR. The missing antihypertensive and antidiabetic medications were promptly administered to Mr. Smith.
On the morning of the second postoperative day, the nurse responsible for Mr. Smith's care mistakenly administered Oxycodone 10 mg instead of the prescribed 5 mg. Within an hour of receiving the higher dose of Oxycodone, Mr. Smith experienced a significant drop in blood pressure, leading to dizziness and lightheadedness. The nursing staff promptly identified the error when they noticed the unexpected change in vital signs during routine monitoring.