patient medication error case report lasix

The nurse who was passing medications noted the line for Lasix had been yellowed out, which she interpreted to mean the medication was discontinued. She was the same nurse who passed the medications on the unit for three days in a row. On 11/7/2008, having interpreted that the medication was discontinued earlier, removed the Lasix from the medication cart to be sent back to the pharmacy. It was picked up to return to the pharmacy on 11/8/2008.

Full Answer

What is a medication error in nursing?

Medication Errors and Nursing Medication errors are normally characterized as deviations from a doctor’s structure. Sources of errors could be from ordering, prescribing, transcription, dispensing, and administration errors (i.e. when the patient is administered a wrong medicine).

Can predesigned labels prevent medication errors in hospitalized patients?

MG Predesigned labels to prevent medication errors in hospitalized patients: a quasi-experimental design study Medwave 2017 17 e7038 Google Scholar Crossref Search ADS PubMed WorldCat 100. SHoHani M

Does nurse staffing affect medication errors in community hospitals?

Nurse staffing is an important strategy to prevent medication errors in community hospitals Nurs Econ 2012 30 288 Google Scholar PubMed OpenURL Placeholder Text WorldCat 90. Kalisch

Is there a systematic review of medication errors in pediatric patients?

Systematic review of medication errors in pediatric patients Ann Pharmacother 2006 40 1766 76 Google Scholar Crossref Search ADS PubMed WorldCat 60. Riaz MK Riaz M Latif A Review - medication errors and strategies for their prevention

Which situation is an example of a medication error?

If a medication error occurred, but didn't hurt anyone, it's called a potential adverse drug event. An example of a medication error is taking an over-the-counter product that contains acetaminophen (Tylenol, others) when you're already taking a prescription pain medicine that contains this exact ingredient.

What is the greatest cause of medication error in healthcare?

Common causes of medication error include incorrect diagnosis, prescribing errors, dose miscalculations, poor drug distribution practices, drug and drug device related problems, incorrect drug administration, failed communication and lack of patient education.

What are 5 common causes of medication errors?

Types of Medication ErrorsPrescribing.Omission.Wrong time.Unauthorized drug.Improper dose.Wrong dose prescription/wrong dose preparation.Administration errors including the incorrect route of administration, giving the drug to the wrong patient, extra dose or wrong rate.More items...•

What is the most common type of medication error?

The most common types of reported errors were wrong dosage and infusion rate. The most common causes were using abbreviations instead of full names of drugs and similar names of drugs. Therefore, the most important cause of medication errors was lack of pharmacological knowledge.

What are the top 5 medication errors?

Top 10 medication errors and hazards, according to medication...Unsafe overrides with automated dispensing cabinets.Unsafe use of IV push meds. ... Wrong route errors with tranexamic acid. ... Unsafe labeling of prefilled syringes and infusions by compounders. ... Using syringes for vinca alkaloids. ... Zinc overdoses. ... More items...•

What are the top 5 medical errors?

Eight common medical errors that harm patients are:Diagnostic Errors and Mistakes. ... Medication Errors. ... Surgical Errors. ... Labor and Delivery Errors. ... Anesthesia Errors. ... Failure to Obtain Informed Consent. ... Communication Errors. ... Infections and Secondary Complications.

How are medication errors reported?

Medication errors are detected by voluntary reporting, direct observation, and chart review. Organizations need to establish systems for prevention of medication errors through analyzing the cause of errors to identify opportunities for quality improvement and system changes (Morimoto, Seger, Hsieh, & Bates, 2004).

What should you do in case of medication error?

How to deal with medication errorsEstablish the extent of the problem. Dealing with your patient's clinical wellbeing must of course be the first step. ... Sources of information. ... Inform the patient. ... Put it right where possible. ... Reporting. ... Investigate further and review systems.

How do you solve medication errors?

10 Strategies to Reduce Medication ErrorsMINIMIZE CLUTTER. ... VERIFY ORDERS. ... USE BARCODES. ... BE AWARE OF LOOK-ALIKE SOUND-ALIKE (LASA) DRUGS. ... HAVE A SECOND PAIR OF EYES CHECK PRESCRIPTIONS. ... DESIGN EFFECTIVE WARNING SYSTEMS. ... INVOLVE THE PATIENT. ... TRUST YOUR GUT.More items...•

What are the common medication errors encountered by nurses?

Seven common medication errors in nursing homes include:Providing patients with the wrong medications. ... Prescribing the wrong dosage. ... Ignoring patient medical histories. ... Providing medications that should not be taken together. ... Improperly administering medications. ... Failing to provide medication. ... Improper preparation.

Who is most affected by medication errors?

The analysis of medication errors shows two high-risk categories: children of less than 5 years of age, in whom the dose was not correctly adjusted, and elderly people with chronic medication and insufficient control of their medication level. Therefore, the measures for risk reduction should focus primarily on them.

What are the top five medications implicated in most medication errors in the hospital?

Reporting Medication Errors The top five medications were hydromorphone, desmopressin, epinephrine, heparin, and morphine. Opioids continue to be the top medication classes associated with harmful incidents reported.

What is the most common cause of medical errors?

Communication Problems Communication breakdowns are the most common causes of medical errors. Whether verbal or written, these issues can arise in a medical practice or a healthcare system and can occur between a physician, nurse, healthcare team member, or patient. Poor communication often results in medical errors.

What is the root cause of medication errors?

Most notably, root cause analysis can help identify medication errors such as illegible handwritten prescriptions, similar name packaging or misleading presentations of drug strength or dosage, ineffective control of prescription labels, and lapsed concentration due to interruptions.

What's the most common type of medical error in hospitals?

Misdiagnosis. The most common type of medical error is error in diagnosis. This is not surprising, since the right diagnosis is the key to your entire medical error. A wrong diagnosis can result in delay in treatment, sometimes with deadly consequences.

What factors contribute to medication errors?

[8] Studies show that some factors such as medication miscalculations, lack of knowledge and proficiency as well as neglecting the hospital's medication protocol due to lack of time, extreme tiredness, inadequate work experience and inappropriate work environment may all be related to the medication errors made by the ...

What are prescription drug errors?

While some prescription drug errors are clear-cut cases of medical malpractice, such as administering the wrong medication or the wrong dose of a medication, prescribing a drug that the patient has previously reported as an allergen or mislabeling a medication, some other drug-related errors are less concrete.

What is Lasix used for?

Lasix is one of the first lines of treatment used to treat edema in those with congestive heart failure, liver disease or certain kidney disorders as well as high blood pressure. 1. But there is a potential problem with the controversial drug, which is often prescribed for those with chronic congestive heart failure.

How does Lasix work?

Lasix works by encouraging the kidneys to release more fluid, and although the drug works to help reduce fluid surrounding the heart, allowing the heart to pump more effectively, there are serious risk factors. Lasix can leave a patient so dehydrated that electrolytes become imbalanced enough to become deadly.

What happens if a doctor fails to check prescriptions?

If your loved one’s doctor failed to check prescription medications, a move that resulted in heart or lung failure, you may likely have a medical malpractice suit against the physician, hospital or other parties.

Why is knowing what drugs a patient is taking important?

Because of prescription drug interactions and other factors, knowing what drugs a patient is taking is a vital part of patient care, and failure to do so is a serious misstep that goes against the doctor’s oath to first do no harm.

Can Lasix be used for congestive heart failure?

If a patient is suffering from chronic congestive heart failure and is being treated with Lasix, then experiences an acute episode of congestive heart failure, Lasix can be deadly, either if a patient is prescribed it and a doctor fails to make note of it in the case of a health emergency or if a doctor prescribes it to treat the wrong condition.

What did the intensive care nurse fail to do?

The intensive care unit nurse failed to notify the physician that the patient’s heart rate was continuing to rise. She failed to follow the physician’s medication orders by administering an incorrect dosage of potassium at an incorrect rate. She then failed to properly document her actions.

What time did the attending physician call the hospital?

According to hospital records, the attending physician was called at approximately 10:00 p.m. and was advised that the patient had gone into cardiac arrest. The on-call emergency physician attempted to resuscitate, but was unable to obtain a heartbeat and the patient was pronounced dead.