Class: Information Management In Healthcare Case Study: AMedication Error
A Patient was admitted to the intensive care unit (ICU) for acardiac-related problem. On admission to the unit, the physicianordered”Inderal 20 mg orally q 6 hours. If patient cannot take POmedications, give 1 mg Inderal IV q 6 hours.’ Later that day, thepatient was transferred to a step-down unit. As required by thehospital’s policy, an ICU nurse rewrote the patient’s orders beforeher transfer to the step-down unit.
However, the initial order was miscopied as “Inderal 20mg orallyq 6 hours; if patient cannot take PO give Inderal IV. On thepatient’s arrival in the step-down unit, the admitting nurse askedthe unit clerk to call the pharmacy for additional ampules ofintravenous Inderal because the unit did not have enough in floorstock to administer a 20-mg infusion. The unit clerk gave noinformation about the patient or the specific order to thepharmacist. The pharmacist questioned this request and found thefollowing information about IV Inderal in the MICROMEDEX: “The IVform of the Inderal(propranolol) can be infused at a maximum rateof 2 to 3 mg per hour. In clinical practice, the amount of IVpropranolol required to replace PO propranolol varies depending onindividual pharmacokinetics and other clinical circumstances.
An IV dose of 10% of the oral dose may be used temporarily toreplace the oral dose in patients undergoing surgery.” Using theMICROMEDEX information as a guideline, the pharmacist talked withthe patient’s nurse and they agreed the patient should receive aninfusion of 3mg/hour. The pharmacy sent thirty 1-mg propranololampules to the unit, and the nurse prepared an 18mg(18 ampules)infusion to run in over 6 hours. After receiving 24 mg ofpropranolol over approximately 8 hours, the patient’s bloodpressure 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 lastingeffects of the lasting effects of the medication error.
1. What departments should be represented on the root causeanalysis team that investigates this patient incident?
2. What evidence should be presented to the root cause analysisteam that investigates this patient incident?
3. On the basis of your research of the literature and therecommendations from national and state organizations involved inreducing medication errors, what appear to be the root causes(s) ofthis event? Cite the references you used in selecting each rootcause.
4. On the basis of your search of the literature and therecommendations from national and state organizations involved inreducing medication errors, what process changes need to occur atthis hospital to prevent similar medication errors fromoccurring?
