Medication error1

Critical incident analysis

Description

This incident about on medication error and a nurse negligence .Medication error is a failure in
the treatment process that leads toor has the potential to lead to harm to thepatient (WHO 2017)
.Medication error that I was noted on knowledge base error.

The mediation error was occurred in a patient 36year old male came in emergency for I&D
incision drainage and doctor prescribed him injection ceftriaxone 1g intravenous stat .The second
year diploma nursing student’s administrated injection ceftriaxone Iv stat independently without
test dose and without asking from her senior three charge nurses.Although other nurses were
busy to take care of another patient.As the student administered injection patient developed
rashes on whole body and patient complaint of palpitation shortness of breath and suddenly went
into hypotension.

As the condition of the patient started deteriorating the attendant shouted on student that she
gave wrong injection to our patient.The attendant was furious and misbehaved the situation was
uncontrolled .All staff of emergency department gathered patient was shifted to the medical
emergency Red Zone for management of anaphylactic shock .The emergency resuscitation was
done and with half an hour medical assistance the patient was reverted into better condition.

Feelings

I was the witness to this incident and initially my first reaction was that I got very nervous and
was unable to figure out the situation .The life of the patient was of my first concern and I felt
concerned about the life of patient under anaphylactic shock.

This incident was important to me because being a nurse it is my foremost job to provide and
safety to my all patients under my care.According to condition of the patient it was very much
miserable and recovery of the patient was not sure .I also felt shock and uncomfortable because
she did work as a novice studentand I was not expecting this type of negligence and not
following the other knowledge of medication of antibiotics.
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Evaluation

Administration of medication is a key element of nursing care .Drug administration plays a

major part of clinical nurse role.The most significance thing of this incident was the negligence
of the nurse student which lead to potential complication .Second reason was workload on staff
nurses and also their negligence they did not supervise the students that lead to harmful
consequence for patient .Shedid not follow the seven rights of medication.

Antibiotic allergy occurs when immune system becomes hypersensitive to the drug mistakenly
reacting to the drug as harmful substance (http/www.myoclinic .Org)

A study was conducted in united states ,42%of the nurses mentioned that’s there was no factor
causing their error while 23.6%referred carelessness and direction of nurses mentioned that there
was no factor causing their while 23.6% referred to carelessness and distraction of nurses .And
11.3%referred to long working as the factor causing medication errors.(Cousins DH et
,2010).Negligence and carelessness nurses during execution of drug order is very important
subject while is affected by different factor such as fatigue caused by high work load .(Ghasemi
F 2013).The risk medication errors among nurses due to negligence is high in the emergency
departments .The rate of reporting medication error due to negligence among nurses was far less
than the medication error they had made and this indicates a gap between the actual rate of
medication error and the reporting rate among nurses (Ehsan et .al,2013)

In a review of medication error incidents reported to the national reporting and learning systems
(NRLS) over six year between 2005to 2010 there were 525,186 incidents reported of these
86,821(16%) of medication incidents actual patient harm ,822(0.9%) resulted in death or sever
harm(cousins et al 2012).

Analysis

Medication errors occur when weak medication system and human factors such as fatigue, poor
environmental condition or staff shortage affecting prescribing transcribing, dispensing,
administration and monitoring practice which can that result in sever harm, disability and even
death ‘(WHO 2017)
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As I critically analyzed the situation I suggest that it’s all about her negligence and carelessness
on duty charge nurse. I analyzed that a mistaken and negligence of medication
administrationneed to carefullyadministration using seven medication right and identify the
patient drug allergy history and need to keep deep observation while students administer
medication .We all concern with the life of our patient concerning is so important to save the life
of others Its all depends on medical staff hands and knowledge.

Conclusion

This was related to my clinical practice in a way that being a nurse it is my responsibility to
follow the rights of medication and knowledge of drug administration and reaction knowledge is
must for every nurse students and do their best to prevent patient from complication .Being a
nurse I must avoid the negligence behavior and work for the health promotion of the client.

Medication error result from both human and system failure .I concluded that medication error
can be reduced through increasing the number of nursingstaff, adjusting the workload of medical
staff in the emergency department and training classes on drug administration. Need to revise
curriculum diploma nursing students and addition of pharmacology in their syllabus.

Encourage nurses to report medical errors and encourage hospital manager to respond to errors in
a positive ethical and logical manner in order to enhance patient safety.

WHO suggests that medication errors could be preventable at different .whilst there is robust
legislation and guidelines to ensure patient safety particularly in relation to the administration of
medicine,following simple and practical steps such as 10right of medication administration can
greatly reduce the risk of errors and literally save lives.

To improve the quality care we must identify the errors made by newly medical staff members’
proper orientation with drug will also give to nursing students to prevent medication errors
proper arranged classes on rights of medication administration.

Team leader should take proper check and balance in administration medicine by the
bedsideThey play vital role in ensuring patient safety by recognizing and reducing
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complication.Encourage nursing student to enhance their knowledge regarding medication avoid

medication error,
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References

 Ghasemi F,Valizadeh F,Nasab M,2013,Analyzing the knowledge and attitude

of nurses regarding medication errors and its prophylactic ways in education
and therapeutic hospital of Khorramabad;pubmed 10[2]-63
 Gilberto buzzi, 15june,2017 Medication error
 J.k.Aronson: An international journal of medicine ,Volume 102,issue
8,August 2009pages 513-521,https://doi.org/10.1093/qjmed/hcp05