patient medication error case report lasix omission

How to assess medication errors occurrence?

Grouping of medication errors occurrence into contextual, modular, or mental (psychological) is considered an ideal protocol to assess how errors happen. Contextual order assesses the specific time, place, medications, and individuals who are included.

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

How did the facility staff respond to the medication and laboratory errors?

The facility staff recognized the medication and laboratory errors, and actions were taken to prevent this error from recurring.

How common is the omission of prescribed medications during hospital stay?

The results showed that the omission of prescribed medications remains a problem throughout the hospital stay of the patient. Among the charts studied, 73% had omitted medications. The most common cause of omission was patients' refusal (47.22%), followed by patients' inability to take the medicine (22.7%).

Which is an example of an omission error pharmacy?

Omission errors are when either a hospital physician fails to order a vital medication that a patient is on at home, a nurse fails to administer a drug as prescribed, or a pharmacist fails to dispense a prescription.

What is a medication error of omission?

A drug omission occurs when a patient does not receive a medication that has been ordered or when a medication has not been ordered despite being appro- priate for an underlying condition.

What should be included in a medication error incident report?

The process of reporting is represented by filling out an ME report form, which consists of demographic data of the patient, medication involved in the error, and factual description of the medication errors.

What are 5 examples of common medication errors and their potential consequences?

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 error of omission with example?

An error of omission happens when you forget to enter a transaction in the books. You may forget to enter an invoice you've paid or the sale of a service. For example, a copywriter buys a new business laptop but forgets to enter the purchase in the books.

What are common omissions on prescriptions?

Among the charts studied, 73% had omitted medications. The most common cause of omission was patients' refusal (47.22%), followed by patients' inability to take the medicine (22.7%). Medication unavailability came third (17.04%).

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 information must be included in an incident report regarding the occurrence?

The date, time and place of the incident or accident. Clear, concise and objective data about the occurrence and any surrounding factors, like a wet floor, that may have led to the incident or accident. The name of the person or persons who was affected with the incident or accident.

How do you correct documentation errors?

Proper Error Correction ProcedureDraw line through entry (thin pen line). Make sure that the inaccurate information is still legible.Initial and date the entry.State the reason for the error (i.e. in the margin or above the note if room).Document the correct information.

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?

These frequent errors can lead to negative consequences for the patients and those who love and care for them.Misdiagnosis. ... Medication Error. ... Faulty Medical Devices. ... Infection. ... Failure To Account For Surgical Equipment. ... Improper Medical Device Placement.

What are 5 common causes of medication errors?

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 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.

Why was the recheck not done?

The recheck was not done because the resident was at dialysis at the time, and neither nurse on duty was aware that the lab was not done. On 10/21 the nurse who signed off the alert wrote—INR 2.2, but no Coumadin. The check off for labs on 10/24 indicated there was no Coumadin order.

How much Coumadin was administered to a resident?

The 6 mg. of Coumadin was administered to the resident. The supervisor called the staff member doing the investigation because the resident’s O2 was down. The resident was given oxygen, but her oxygen level did not improve, so she was transferred to the hospital on 10/25.

What happened to the patient who was rushed to the ER with anaphylaxis?

They rushed her to trauma, where a nurse administered epinephrine to help alleviate her symptoms. Immediately, the patient felt severe, crushing pain flow through her body that caused her to pass out.

How early did the nurse give the meds to the patient?

The night before his surgery, a nurse saw that the patient was expected to receive meds at 6 a.m., but he was also slated to leave for the operating room before 6 a.m. To keep him from skipping a dose, she administered the medication two hours early, at 4 a.m.

What is QTC prolongation?

According to the Agency for Healthcare Research and Quality (AHRQ), which published the case study, the patient was found to have “severe QTc prolongation on his electrocardiogram, putting him at high risk for torsades de pointes, a sometimes fatal arrhythmia.” As a result, they had to postpone his surgery until his QTc returned to its regular level.