Medication Error Root Cause Analysis

Case Study: A Medication Error

A patient was admitted to the intensive care unit (ICU) for a cardiac-related problem. On admission to the unit. The physician ordered “Inderal 20 mg orally q 6 hours. If patient cannot take PO medications, give 1 mg Inderal IV q 6 hours.” Later that day. The patient was transferred to a step-down unit. As required by the hospital’s policy. An ICU nurse rewrote the patient’s orders before her transfer to the step-down unit. However. The initial order was miscopied as “Inderal 20 mg orally q 6 hours; if patient cannot take PO give Inderal IV.”

 

On the patient’s arrival in the step-down unit. The admitting nurse asked the unit clerk to call the pharmacy for additional ampules of intravenous Inderal because the unit did not have enough in floor stock to administer a 20-mg infusion. The unit clerk gave no information about the patient or the specific order to the pharmacist. The pharmacist questioned this request and found the following information about IV Inderal in the MICROMEDEX:

patient’s physician

“The IV form of Inderal (propranolol) can be infused at a maximum rate of 2 to 3 mg per hour. In clinical practice. The amount of IV propranolol required to replace PO propranolol varies depending on individual pharmacokinetics and other clinical circumstances. An IV dose of 10% of the oral dose may be used temporarily to replace the oral dose in patients undergoing surgery.”

 

Using the MICROMEDEX information as a guideline, the pharmacist talked with the patient’s nurse, and they agreed the patient should receive an infusion of 3 mg/hour. The pharmacy sent 30 1-mg propranolol ampules to the unit, and the nurse prepared an 18-mg (18 ampules) infusion to run in over 6 hours.

 

After receiving 24 mg of propranolol over approximately 8 hours. The patient’s blood pressure dropped to 70/50 mm Hg, and she complained of dizziness. The infusion was stopped. The patient’s physician was contacted. The patient was placed on a cardiac monitor and watched closely. Her symptoms eventually subsided. There were no apparent lasting effects of the medication error.

The assignment:

 

patient’s physician

Write a 2-page ‘executive summary’ report that includes:

·  introduction, incident description, contributing and root causes. Conclusions,and risk reduction strategies.

 

You will need to utilize resources other than your text book to complete this assignment. Please cite your references.

 

Your assignment should include answers to the following questions:

 

1) What departments should be represented on the root cause analysis team that investigates this patient incident?

 

 

2) What evidence should be presented to the root cause analysis team. Evidence includes written or verbal testimony. Physical evidence. And documents. Be as specific as possible.

 

3) On the basis of your research (such as recommendations from national and state organizations involved in reducing medication errors). What appears to be the root cause(s) of this event. Cite the references you used in selecting each root cause.

 

4) What process changes need to occur at this hospital to prevent similar medication errors from occurring. Cite the references you used in selecting each of your process improvement/risk reduction recommendations.

Diabetes and Drug Treatments

 

Each year, 1.5 million Americans are diagnosed with diabetes (American Diabetes Association, 2019). If left untreated, diabetic patients are at risk for several alterations, including heart disease, stroke, kidney failure, neuropathy, and blindness. There are various methods for treating diabetes, many of which include some form of drug therapy. The type of diabetes as well as the patient’s behavior factors will impact treatment recommendations.

For this Discussion, you compare types of diabetes, including drug treatments for type 1, type 2, gestational, and juvenile diabetes.

 

To Prepare

 

· Review the Resources for this module and reflect on differences between types of diabetes, including type 1, type 2, gestational, and juvenile diabetes.

type of diabetes to focus on for this Discussion.

· Consider one type of drug used to treat the type of diabetes you selected, including proper preparation and administration of this drug. Then, reflect on dietary considerations related to treatment.

· Think about the short-term and long-term impact of the diabetes you selected on patients, including effects of drug treatments.

 

By Day 3 of Week 5

 

Post a brief explanation of the differences between the types of diabetes, including type 1, type 2, gestational, and juvenile diabetes. Describe one type of drug used to treat the type of diabetes you selected, including proper preparation and administration of this drug. Be sure to include dietary considerations related to treatment. Then, explain the short-term and long-term impact of this type of diabetes on patients. Including effects of drug treatments. Be specific and provide examples.

Statistical Package for Social Sciences

Evidence Based Practices to Guide Clinical Practices

Introduction

Nurses can keep up to date wit

h all the data compiled from clinical research and evidence-based practice thanks to developments in communication technology, which has resulted in a vast expansion of knowledge and information. Understanding basic research designs and processes can help you differentiate quality research from credible sources with verifiable data. The aim of this paper is to assess different aspects of two research studies that have been published in clinical journals and concentrate on the successful integration of self-management and healthy lifestyle habits in the areas of hand washing and nosocomial infections (Camargo et.al, 2018). Each author aims to illustrate the useful insight into the advantages and drawbacks of each and their implementation in clinical practice by contrasting the elements from quantitative and qualitative research studies.

developments in communication technology

Interrelationship between Theory, Research, and EBP

Evidence based on practice, research and theory are the pillars of the nursing profession. These three concepts interact in a reciprocal and cyclical way. Medical evidence-based practice generates empirical issues and expertise in theory (Ellis, 2019). Research informs evidence-based practice and advances understanding by advancing hypotheses. Theoretical frameworks direct studies and help to strengthen evidence-based practice.

Successful nursing practice entails treating patients with experience, expertise, compassion, and imagination in an accessible, safe, and considerate manner. Research findings represent an important part of the knowledge involved in the decision-making of nursing health. Ideally, all recommendations on medical care base on research evidence.

Study and theory have a reciprocal relationship in which research generates further information and theory. Theory is essential to the research process, as it serves as a backdrop for providing insight and guidance to the research sample (Camargo et.al, 2018). Theory may also guide the study process by developing and testing hypotheses of interest. Practice is the basis for the development of nursing theory, while nursing theory must be substantiated in practice.

Statistical Package for Social Sciences

Article 1

Asadollahi, M., Bostanabad, M. A., Jebraili, M., Mahallei, M., Rasooli, A. S., & Abdolalipour, M. (2016). Nurses’ knowledge regarding hand hygiene and its individual and organizational predictors. Journal of caring sciences, 4(1), 45

Research Questions

Does apposite hand washing among healthcare practitioners decreases nosocomial infections transmission rates to patients.

Sampling and Sampling Size

Survey method with questionnaire administered to 150 employed nurses in selected settings

The study setting was Tabriz teaching hospitals. Study population is employed nurses in the study area who were participated after census sampling.

Research Design

The researchers created questionnaires to assess participants’ knowledge of hand hygiene, which were then used after they were approved for reliability and validity.

Hypothesis

Due to nurse’s critical roles, they should have essential and updated information concerning hand hygiene.

Data Collection Methods

The study embraced a descriptive and cross-sectional design, with the researchers using a questionnaire as the research tool. The questionnaire design based on literature, guidelines, and article reviews. The qualitative study of the research applied Statistical Package for Social Sciences (SPSS) by descriptive statistics and the Pearson correlation test. The t-test on independent samples and one way ANOVA were used, hence the significance of qualitative methodology to respond to the study question.

Discussion:

Despite increased abilities across developmental realms, including the maturation of pain systems involving self-regulation and the coordination of affect and cognition, the transition to young adulthood is accompanied by higher rates of mortality, greater engagement in health-damaging behaviors, and an increase in chronic conditions.  Rates of motor vehicle fatality and homicide peak during young adulthood, as do mental health problems, substance abuse, unintentional pregnancies, and sexually transmitted infections. 

Describe how the advanced practice nurse can play a role in improving the health of young adults through preventive screening and intervention.

Instructions: 

Word limit 500 words.  Support your answers with the literature and provide citations and references in APA format.  Reply to at least two other student posts with a reflection of their response.