A physician wrote a prescription for “.5 mg IM morphine for postoperative pain” for a 9-month-old infant. The unit secretary recorded the order in the MAR as “5 mg.” An inexperienced nurse followed the directions on the MAR without question and gave the baby 5 mg of IM morphine initially and another 5-mg dose 4 hours later. About 2 hours after the second dose, the baby stopped breathing and experienced respiratory arrest. If the physician had written “0.5 mg,”

QUESTION

A physician wrote a prescription for “.5 mg IM morphine for postoperative pain” for a 9-month-old infant. The unit secretary recorded the order in the MAR as “5 mg.” An inexperienced nurse followed the directions on the MAR without question and gave the baby 5 mg of IM morphine initially and another 5-mg dose 4 hours later. About 2 hours after the second dose, the baby stopped breathing and experienced respiratory arrest. If the physician had written “0.5 mg,” the unit secretary would probably not have had any misunderstanding of the intended amount, and the nurse would have administered the correct dose.

Critical thinking Questions

Although the initial error was not the nurse’s, what steps should he or she have taken to avoid this medication error?

What measures could the facility implement to curtail future medication errors?

Explain how using a standardized written measurement system would have prevented this adverse drug event.

What technology is available to help prevent errors and has it been successful?

Note: Provide at least one additional resource in addition to the textbook to answer the question.

Research Question

Substance abuse and misuse have become a national concern. Select a substance, research solutions and provide a plan for your patient. You must support your plan with a minimum of two resources plus the textbook.

Write a 1500 word essay or a PowerPoint addressing each of the following points/questions. Be sure to completely answer all the questions for each bullet point.

Essay – Separate each section in your paper with a clear heading that allows your professor to know which bullet you are addressing in that section of your paper. Support your ideas with at least three (3) citations in your essay. Make sure to reference the citations using the APA writing style for the essay. The cover page and reference page do not count towards the minimum word amount.

ANSWER

Medication Error and Patient Safety: Lessons Learned and Preventive Measures

Introduction

Medication errors pose significant risks to patient safety and can have detrimental consequences. In the case presented, a prescription error led to an adverse drug event in a 9-month-old infant. This essay aims to analyze the steps that the nurse could have taken to avoid the error, discuss measures that the facility can implement to prevent future medication errors, emphasize the importance of standardized written measurement systems, and explore available technologies for error prevention.

Avoiding the Medication Error

Although the initial error was not the nurse’s, it is crucial for healthcare professionals to be diligent and take appropriate steps to prevent medication errors. In this situation, the nurse should have double-checked the medication order against the medication administration record (MAR) before administering the drug. By cross-verifying the prescribed dose of 0.5 mg with the recorded dose of 5 mg, the nurse would have noticed the discrepancy and sought clarification from the prescribing physician or a pharmacist. Verifying the order is an essential step in ensuring accurate medication administration.

Preventing Future Medication Errors

To curtail future medication errors, healthcare facilities can implement several measures. First, comprehensive education and training programs should be provided to all healthcare staff involved in medication administration. These programs should focus on error prevention strategies, the importance of double-checking orders, and effective communication within the healthcare team. Secondly, the facility can establish a culture of safety by encouraging reporting of near-misses and adverse events without fear of retribution. This fosters a learning environment where errors are seen as opportunities for improvement rather than occasions for blame. Additionally, implementing electronic prescribing systems and barcode scanning technology can help reduce errors by automating the medication administration process and providing real-time alerts for potential drug interactions or dosage errors.

The Role of Standardized Written Measurement Systems

The use of standardized written measurement systems, such as the International System of Units (SI), plays a vital role in preventing medication errors. In this case, if the physician had written “0.5 mg” instead of “5 mg,” the unit secretary would have been less likely to misinterpret the intended amount. Standardized systems provide clarity and consistency in medication orders, minimizing the risk of miscommunication and errors. By adopting standardized measurement systems, healthcare facilities can enhance patient safety and improve accuracy in medication prescribing, transcribing, and administration.

Technologies for Error Prevention

Several technologies have been developed to help prevent medication errors and improve patient safety. Computerized physician order entry (CPOE) systems enable physicians to directly enter medication orders electronically, reducing the chances of misinterpretation or transcription errors. Barcode scanning systems can be used during medication administration to verify the right medication, dose, and patient, ensuring accuracy at the bedside. Additionally, electronic medication administration records (eMAR) can provide real-time information on medication administration, alerting healthcare providers to potential errors or omissions.

Conclusion

Medication errors can have severe consequences for patients, emphasizing the importance of implementing measures to prevent such incidents. Healthcare professionals should actively participate in error prevention strategies, including double-checking medication orders and fostering open communication within the healthcare team. Standardized written measurement systems and technological advancements, such as electronic prescribing and barcode scanning, offer additional layers of protection to mitigate medication errors. By embracing a culture of safety and utilizing available technologies, healthcare facilities can work towards ensuring optimal patient outcomes and minimizing the occurrence of medication errors.