Discuss and describe the type of medication error that occurred in this scenario.
Pharmacology in Nursing Short answer topics
Order Description
There are topics to address two mini essays if you will the first topic is below.
1st -Read this clinical summary
This case study is a summary of where a medication error contributed to the cause of death. It is a real life incident of a coronial investigation obtained from public documents. A document becomes public once the coronial investigation process has been completed and closed. All individuals and facilities are de-identified. Some details have been removed which was deemed unnecessary for this Assessment piece.
CLINICAL SUMMARY
Mrs C was a 69-year-old female with a complex medical history of stroke with a residual left side weakness and ongoing risk of aspiration atrial fibrillation and insulin-dependent diabetes mellitus. She was more recently diagnosed with a suspected left ear tumour. Mrs C had a planned admission to a metropolitan hospital for a biopsy.
Mrs C was commenced on oral antibiotics (ciprofloxacin) after the biopsy results suggested an infection. One day after the procedure her oxygen saturation levels dropped and staff suspected she had aspirated. A nasogastric tube (NGT) was inserted but was pulled out by Mrs C a day later. Despite advice from healthcare professionals about the risk of further aspiration and sub-optimal oral nutrition neither Mrs C nor her immediate family would consent to the reinsertion of a NGT.
Three days later following another episode where Mrs Cs oxygen saturation levels dropped x-rays showed acute pulmonary oedema with right lower lobe consolidation and an ECG demonstrated Mrs C had rapid atrial fibrillation. For these reasons Mrs C was transferred to the Intensive Care Unit (ICU) where a NGT was re-inserted.
The nurse-in-charge (NIC) left instructions that Mrs Cs oral ciprofloxacin ought to be crushed and administered through the NGT tube. Later that same evening blood tests were required and the nursing staff realised that Mrs Cs evening medications including the oral ciprofloxacin and intravenous frusemide had not yet been administered.
The nurse (RN. R) looking after Mrs C was asked to take the bloods via a peripherally inserted central catheter (PICC) and to administer the medications. As she had not had prior experience of PICC lines she was supervised by another nurse (RN. C). RN. R was instructed to crush the ciprofloxacin to enable NGT administration but then drew the paste into a standard sized non-luer lock syringe even though she intended to administer the medication via the NGT which required a larger nozzle. RN. C drew up the frusemide and both medications were placed into a kidney dish. At the bedside RN. R took blood from the PICC line and administered the intravenous frusemide. The NIC was present at the time attending to Mrs Cs NGT feeding. The NIC informed RN. R that medications administered via a PICC needed to be drawn up in a luer lock syringe. RN. R returned to the drug room and transferred the crushed up ciprofloxacin into a luer lock syringe injecting it into the PICC line.
A short time later Mrs C became cyanosed and hypoxaemic then unresponsive. Since Mrs C was subject to a NFR (not for resuscitation) order a code blue was not called. She was pronounced deceased soon after.
An autopsy performed later found foreign material in the vessels of the brain lungs and heart.
INVESTIGATION
Looking primarily at the circumstances in which Mrs C had died the coroner at inquest focussed on several issues. 1 of these specifically included:
The adequacy of remedial measures taken by the health service to minimise the risk of such errors in drug administration.
The Director of Medical Services gave evidence that a number of safety measures had since been implemented by the hospital following an internal investigation.
. Write 500-600 words addressing the following questions:
a) Discuss and describe the type of medication error that occurred in this scenario.
b) The Director of Medical Services gave evidence that a number of measures had been
implemented following an investigation using a root cause analysis of this incident.
Discuss 1 (one) or 2 (two) safety measures that you feel would have been implemented to
minimise the risk of such an error in drug administration occurring again.
2nd Topic- Understanding pharmacokinetics (PK) is important for safety administrating medications to patients.
However the PK of drugs are altered by age i.e. in the elderly population group when compared to
adults.
Discuss PK i.e. absorption distribution metabolism and excretion that includes one aspect (for each
part) that differs in the elderly in comparison to adults. Include in your discussion at least 2 (two) to 3 nursing implications/interventions to ensure safety in administering medications to this population group.
“,Pharmacology in Nursing Short answer topics
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