Class: Information Management In Healthcare
Avoiding Liability
Case Study: A Medication Error A Patient was admitted to theintensive care unit (ICU) for a cardiac-related problem. Onadmission to the unit, the physician ordered”Inderal 20 mg orally q6 hours. If patient cannot take PO medications, give 1 mg InderalIV q 6 hours.’ Later that day, the patient was transferred to astep-down unit. As required by the hospital’s policy, an ICU nurserewrote the patient’s orders before her transfer to the step-downunit.
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 IVdose of 10% of the oral dose may be used temporarily to replace theoral dose in patients undergoing surgery.”
Using the MICROMEDEX information as a guideline, the pharmacisttalked with the patient’s nurse and they agreed the patient shouldreceive an infusion of 3mg/hour. The pharmacy sent thirty 1-mgpropranolol ampules to the unit, and the nurse prepared an 18mg(18ampules) 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. Directions:Write a report that includes answers to the followingquestions:
1. What departments should be represented on the rootcause analysis team that investigates this patientincident?
2. What evidence should be presented to the root causeanalysis team that investigates this patient incident?
3. On the basis of your research of the literature andthe recommendations from national and state organizations involvedin reducing medication errors, what appear to be the root causes(s)of this 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?
