Medication Error Dale Buchbinder You are a physician making rounds on your patie
ID: 248606 • Letter: M
Question
Medication Error Dale Buchbinder You are a physician making rounds on your patients when you arrive at Mrs. Buckman's room. She's an elderly lady in her late 70s who recently had colon surgery. She is also the wife of a prominent physician at the hospital. She has been known to be somewhat confrontational with the nursing staff. However, today she states she was just given a shot of insulin to cover her elevated blood sugar and the amount of insulin did not seem to be the usual amount. Even though Mrs. Buckman often complains, you are somewhat concerned about this observation and decide that it would be best to check on this. You ask the charge nurse to review the dose of insulin given. She, in turn, finds Mrs. Buckman's nurse, who states that, as ordered, she had given the patient 80 units of insulin. You immediately become quite alarmed, as this is an extraor- dinarily large dosage. You make sure that the patient is given a large amount of glucose supplement and that her blood sugar is monitored every 15 minutes for the next two hours. To follow up, you also review the chart and note an order from the house physician to give Mrs. Buckman 8.0 units of insulin. You can readily see how this could easily appear to be 80 units. You meet with the charge nurse, the nursing supervisor, the Director of Nursing, and the treating nurse to determine what can be done to prevent this type of error in the future.
Explanation / Answer
Part 1:
Steps to be taken to prevent this form in the future:
Physician, charge nurse, Nursing supervisor, Director of Nursing, treating nurse should together discuss the event.
Part 2:
Yes. This case will meet the criteria of sentinel events. According to Joint Commision, insulin comes under high alert medication for patient safety. Common risk factors are lack of dose system of insulin, write of units instead of U to avoid 10-overdose. Joint Commision also recommends the preparation of insulin by one nurse and review it by another nurse to avoid sentinel event.
3. No. The nurse should counter check the ordered dose with the physician. She should have the basic knowledge of the insulin, dose, syringes, and its effects.
4. The nurse doesn't question herself about the large dose of insulin. she might have prevented this event and patient safety can be maintained. Ask 'why' by oneself will help to avoid so many issues.
5. No, the pharmacist did not consider that why the patient is receiving a high dose of insulin.
6. the mechanism should be put in place to avoid the issue should include the crosscheck of insulin order and administration of insulin by one nurse and review by the other nurse.
7. Medication error should be considered as a sentinel event. Root cause analyse should be performed to avoid Misinterpretation of insulin order which leads to the wrong dose of insulin. Avoid using abbreviations( avoid 'U' for units) and trailing zeros (avoid writing 8.0 for 8).