Question

CASE ANALYSIS.

It is the responsibility of the nurse to clarify any drug order that is incomplete – that is, order that does not contain the essential seven parts discussed in this module. Let us look at an example in which this error occurred.

SCENARIO 1: Failing to clarify incomplete orders

Suppose a physician ordered omeprazole capsules p.o. at bedtime for a patient with an active duodenal ulcer. You will note there is no dosage listed. The nurse thought the medication came in only one dosage strength, added 20 mg to the order, and sent it to the pharmacy. The pharmacist prepared the dosage written on the physician’s order sheet. Two days later, during rounds, the physician noted that the patient had not responded well to the medication. When asked about this, the nurse explained that the patient had received 20 mg at bedtime. The physician informed the nurse that the patient should received the 40 mg dosage for high acid suppression.

Potential Outcome:?

Prevention:?

SCENARIO 2. Omitting medication due to incorrect scheduling of dose.

An order was written for ampicillin 500 mg IV PB q4.h, which was handwritten on the medication administration record (MAR). The registered nurse was distracted while verifying the order and writing in the scheduled times of administration. The nurse saw the number 4 and instead of scheduling the medication every 4 hours, scheduled the medication to be given 4 times a day at 6-12-6-12 timing. For 2 days, the shift nurses each checked to see what medication needed to be given on their scheduled shifts but did not take time to compare the ordered frequency to the scheduled times. Eventually a nurse did look over the entire medication record and noticed the error. The medication times were corrected and the doctor was notified. A medication variance form was completed, documenting the error, and it was submitted to the hospital risk management department.

Potential Outcome:?

Prevention:?

Answer 1