As a telemetry technician, the chosen case study involves a nurse who administered an excessive and improper dose of antiarrhythmic medication, leading to an adverse patient outcome.

What went wrong?

The nurse failed to verify the prescribed dosage, cross-check the medication with the patient’s condition, and consult established safety guidelines, resulting in a preventable error. The nurse also failed to verify using the “‘six rights’ when administering medications to patients: Right patient, Right drug, Right dose, Right route, Right time and Right documentation,” (CNA, & NSO. 2023)

What workplace safety, risk management, and/or quality improvement steps were involved?

After the patient’s physical deterioration was observed by the nurse he followed the safety protocol of calling the patients caregiver, the cardiologist, then (at the direction of the cardiologist) 911 for an ambulance.

What could have been done differently?

This incident highlights the lack of adherence to medication safety protocols. There are low-tech and high-tech strategies to improve medication administering practices. MacDowell, et. al (2021) list the following: Standardized communication to ensure right medication, Optimizing Nursing Workflow to Minimize Error Potential which minimizes the distractions that impact patient care, and independent double checks which involves two different nurses to independently verifying medication, dosage, and administration methods as a means to intercept errors prior to administering the medication to the patient.

If you were in charge of making sure this type of event never occurred again, what steps would you implement into the risk management plan?

Knowing this patient’s prognosis, two nurses or a nurse and a nurse tech would have to be present. This not only provides a secondary healthcare professional for independent medication verification but also for the prevention of sentinel events such as falls when the primary nurse cannot handle rolling or picking up a patient on their own. I would also include some form or app that allows electronic charting to document medication administered during the visit, vitals, and other elements of care. The electronic aspect would allow a healthcare professional at the office to quickly verify what was administered. In this case, the overdose would prompt the in-office personnel to call the nurse to immediately check what was administered and patient vitals.

References
Nurse Malpractice Case Study: Administering improper, excessive medication dose and disregard of medication safety: Nurse Medical Malpractice Case Study with Risk Management Strategies, Presented by CNA and NSO. (2023, March 1). New Mexico Nurse, 68(2), 18.

MacDowell P, Cabri A, Davis M. Medication Administration Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.

Authority, Pennsylvania Patient Safety. “The Five Rights: Not the Gold Standard for Safe Medication Practices | Advisory.” Pennsylvania Patient Safety Authority, June 2005, patientsafety.pa.gov/ADVISORIES/Pages/200506_09.aspx.

Hughes RG, Blegen MA. Medication Administration Safety. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 37. Available from: https://www.ncbi.nlm.nih.gov/books/NBK2656/