Question

You are a physician making rounds on your patients when you arrive at Mrs. Buckman’s room. She’s an elderly lady in her late 70s who recently had colon surgery. She is also the wife of a prominent physician at the hospital. She has been known to be somewhat confrontational with the nursing staff. However, today she states she was just given a shot of insulin to cover her elevated blood sugar and the amount of insulin did not seem to be the usual amount. Even though Mrs. Buckman often complains, you are somewhat concerned about this observation and decide that it would be best to check on this. You ask the charge nurse to review the dose of insulin given. She, in turn, finds Mrs. Buckman’s nurse, who states that, as ordered, she had given the patient 80 units of insulin. You immediately become quite alarmed, as this is an extraordinarily large dosage. You make sure that the patient is given a large amount of glucose supplement and that her blood sugar is monitored every 15 minutes for the next two hours. To follow up, you also review the chart and note an order from the house physician to give Mrs. Buckman 8.0 units of insulin. You can readily see how this could easily appear to be 80 units. You meet with the charge nurse, the nursing supervisor, the Director of Nursing, and the treating nurse to determine what can be done to prevent this type of error in the future.

1- What is the Background Statement? What is going on in this case as it relates to the identified major problem? What are (only) the key points the reader needs to know in order to understand how you will “solve” the case? Summarize the scenario

Answer 1

Giving large (wrong) dose of medication to the patient is medication error.

The major problem of administration of large dose of insulin will cause

• Depressed mood
• Dizziness
• Hunger
• Inability to concentrate
• Disorientation
• Nausea
• Nervousness
• Personality changes
• Rapid heartbeat
• Slurred speech
• Pale skin
• Sweating
• Tingling
• Tremor
• Unsteady movements
• Coma
• Disorientation
• Seizures

Medication error can be solve in this case by means of some strategies;

1. Ensure the five rights of medication administration.

2. Follow proper medication reconciliation procedures.

3. Double check or even triple check procedures.

4. Have the physician (or another nurse) read it back.

5. Consider using a name alert.

6. Place a zero in front of the decimal point.

7. Document everything.

8. Ensure proper storage of medications for proper efficacy.

9. Learn your institution’s medication administration policies, regulations, and guidelines.

10. Consider having a drug guide available at all times.

Summarizing the scenario:

Mrs. Buckman should receive only 8.0 unit of insulin instead she received 80 units by nurse and it's a compliance as medication error. The institution should arrange for an audit to rectify this problem and to ensure not to happen by anyone in future.

By following the above 10 strategies will helpful fornthe nurses to avoid such problems in future