CASE STUDY ASSIGNMENT

DUE: JULY 20,2010

LINDA ADAMSON

1.WHAT WAS JOAN'S MISTAKE? WAS THIS AN ACT OF OMISSION, AN ACT

OF COMMISSIONOR A NEAR -MISS? ANSWER: JOAN'S MISTAKE
WAS AN ACT OF COMMISSION. AS SHE GAVE AN ANTIBIOTIC TO
MR. L ANG TO WHICH HE WAS ALLERGIC.

2. WHAT 5 PRIORITY ACTIONS MUST JOAN TAKE UPON REALIZING HER

MISTAKE? GIVE YOUR RATIONALE FOR JOAN'S ACTIONS. ANSWER: 1)
JOAN MUST ASSESS MR. LANGS ALLERGIC REACTION (PATIENT
SAFETY) 2) NOTIFY PHYSICAN (FOR INSTRUCTION) 3)NOTIFY
SUPERIOR OR PEER (FOR DIRECTION AND SUPPORT) 4)
COMMUNICATE WITH MR. LANG (DISPELL ANY FEARS) 5)
DOCUMENT ERROR AND ACTION TAKEN (LEGALLY BOUND)

3.HOW COULD SHE HAVE PREVENTED THIS MISTAKE FROM HAPPENING IN

THE FIRST PLACE? RELATE YOUR ANSWER TO THE STANDARDS OR
PRACTICE FOR MEDICATIONS REVISED 2008. ANSWER: PRACTICE
STANDARD MEDICATION,REVISED 2008 HAS FOUR STANDARD
STATEMENTS WITH INDICATORS THAT DESCRIBE NURSES`
ACCOUNTABILITIES FOR MEDICATION PRACTICE. THEY ARE;
ASSESSMENT, PLANNING, IMPLEMENTATION AND EVALUATION.
WHEN PLANNING TO GIVE THE MEDICATION JOAN COULD HAVE
CHECK THE ORIGINAL ORDER NOTING THE PHYSICIAN , THE
NURSE TRANSCRIBING AND THE PHARMACY ALL FAILED TO
IDENTIFYL MR. LANG WAS ALLERGIC TO THE ANTIBIOTIC. THE
ERROR COULD HAVE ALSO HAVE BEEN AVOIDED BY JOAN, HAD
SHE CHECK THE ALLERGY ALERT ON MARS DURING THE
IMPLEMENTATION OF THE MEDICATION.

4.HOW CAN SHE TELL MR. LANG ABOUT THIS ERROR? ANSWER: JOAN
SHOULD GET THE SUPPORT OF HER SUPERVISOR OR PEER AS
SHE IS HORRIFIED AND UPSET. JOAN NEEDS TO BE CALM AND
SPEAK TO MR. LANG IF HE IS STABLE , IN A PRIVATE,
 COMFORTABLE SETTING AS SOON POSSIBLE AFTER THE
INCIDENT.

5.WHAT MUST JOAN CONSIDER BEFORE TELLING MR. LANG ABOUT THE
MISTAKE? GIVE RATIONALE FOR YOUR ANSWER. ANSWER: JOAN
MUST CONSIDER MR. LANG`S MEDICAL AND EMOTIONAL
CONDITION. SHE ALSO MUST KNOW THE HOSPITALS POLICIES
AND PROCEDURES REGARDING DISCLOSURE OF ERRORS.

6.WHAT MIGHT JOAN SAY? ANSWER: JOAN SHOULD BE HONEST AND

FORTHWRIGHT TELLING MR. LANG ``I MADE AN ERROR THIS
MORNING GIVING YOU AN ANTIBIOTIC THAT YOUR RECORDS
STATE YOU HAVE AN ALLERGY TOO. YOU COULD HAVE AND
ADVERSE REACTION. I HAVE INFORMED THE DOCTOR AND MY
SUPERVISOR. I AM EXTREMELY UPSET AND SORRY FOR MY
ERROR``. JOAN WOULD ASK MR. LANG IF HE HAS ANY
QUESTIONS AND PROVIDE HIM WITH THE FOLLOW-UP
PROCEDURES.

7.WHAT WERE THE COURSE OF EVENTS THAT LEAD TO THE MISTAKE?

ANSWER: JOAN WAS STRESSED AS THIS WAS HER FIRST DAY
AFTER VACATION. SHE WAS LATE AN HAD A HEAVY WORK
LOAD. THERE WERE MANY MEDICATION CHANGES ON THE
MARS WHICH SHE DID NOT TAKE THE TIME TO REVIEW. SHE
DID NOT TAKE THE TIME TO EVALUATE MR. LANGS CONCERNS
OVER THE CHANGE AND INCREASED AMOUNT OF MEDICATION
HE WAS NOW TAKING. JOAN ASSUMED EVERYONE ELSE ON
HER TEAM HAD DONE THEIR JOB PROPERLY. SHE GAVE MR.
LANG FALSE REASSURANCE IN REGARD TO HIS MEDICATION.
JOAN THEN FAILED TO FOLLOW THE `5 RIGHTS`` AND CHECK
THE ALLERGY ALERT ON THE MARS WHILE CHECKING FOR THE
RIGHT MED.

8.WHAT WAS THE NATURE OF THE MISTAKE? ANSWER: DUE TO ERROR

MR. LANG WHO WAS EXPECTING TO GET MEDICAL CARE WAS
ACTUALLY PUT IN ``DANGER FOR HIS LIFE`` BY THE NURSE,
WHO WAS CARING FOR HIM.

9.WHAT ARE SOME POTENTIAL AND ACTUAL CONSEQUENCES? ANSWER:

MR. LANG COULD HAVE AN ADVERSE REACTION TO THE
ANTIBIOTIC WHICH COULD INCLUDE A RASH, S.O.B.,
ANAPHLATIC SOCK AND EVEN DEATH. MR. LANG COULD LOSE
HIS TRUST IN THE MEDICAL SYSTEM. MR. LANG COULD SUE
THE HOSPITIAL AND MAKE A COMPLAINT AGAINST THE NURSE
TO THE CNO ABOUT HER COMPETENCEY. JOAN CONFIDENCE AS
 A NURSE COULD BE AN ISSUE. ACUTUAL CONSEQUENCES ARE
THAT MR. LANG AND JOAN HAVE SUFFERED STRESS FROM THE
ERROR. SO, FAR AN INCIDENT REPORT HAS BEEN
DOCUMENTED WITH JOAN COMMITTING A MED ERROR.

10.WHAT CORRECTIVE ACTION SHOULD BE TAKEN?ANSWER: THE

CHAIN OF EVENTS FROM THE TIME THE ORDER WAS WRITTEN
AND MR. LANG WAS GIVEN THE MEDICATION SHOULD BE
INVESTIGATED BY MANAGEMENT AND PHARMACY AND ALL
PARTIES INVOLVED SHOULD BE AWARE OF THEIR MISTAKE AND
FOLLOW-UP WITH SOME MED-ERROR TEACHING. THESE
PEOPLE SHOULD THEN TAKE STEPS TO REFLECT UPON THEIR
PRACTICE IN RESPONCE TO THIS MISTAKE. THE PHARMACY
MAY LOOK A ALLERGY BRACELETS FOR PATIENTS.