NUR 302 Nursing

The issue that I identified during event review meeting that nurse from Medical/Surgical unit call doctor for 80 years patient for pain medication. Doctor asked the nurse to placed order electronically because he did not have assessed of the computer that specific time. A nurse got telephone order for morphine 2mg intravenous q3hrly. Unfortunately, the nurse gets confused with hydromorphine. A patient accidentally received multiple times an incorrect narcotic drug (hydromorphone instead of morphine), resulting in a fatal result. The nurse, human factors engineering are the core science of patient safety. In analyzing the factors involved in this case, a number of human factors issues were identified throughout the event, as are typically found with other complex catastrophic events. The triggering event, sound-alike drug names, and workplace distraction.

 Communication and medication safety process issues were identified, which reduced the likelihood of early discovery of the overdose once the event occurred. The ability of hospital leadership to create, nourish, and to maintain a culture of patient safety is critical to the success of any organizational changes made to mitigate adverse events. Some of the recommended actions contained in this report are designed to assist the hospital to support this desired culture of safety.

Your journal draws from evidence, concepts, and/or theories you have examined in this program, especially those related to your specialization. What have you observed during your Practicum Experience that you would like to analyze through your journal writing?

The present paper is a reflective journal that analyses an issue faced during the practicum experience on the basis of sources of evidence. The concerned issue being discussed in here relates to an event review meeting where a nurse from the Medical/Surgical unit called the doctor for attending an 80 years old patient for administering pain medication. The doctor requested the nurse to place an order electronically since there was not access to the computer system at that point in time. The nurse called up for ordering morphine 2mg intravenous q3hrly. Much to misfortune, the nurse got confused with hydromorphine. As a result, the patient was administered the incorrect narcotic medication at multiple instances wherein hydromorphine was given in place of morphine. The patient suffered fatal conditions.

It is to be highlighted, while analysing the present scenario, that human factors play a key role in bringing about the fatal patient outcome. Multiple human factors were involved in the event that was responsible for the catastrophic events. These mainly related to workplace distraction, the triggering event and the names of drugs that sounded alike. All these factors were significant throughout the event that remained at the core of patient safety (Moorhead et al., 2014).

According to Zaccagnini and White (2015) nurses required to administer medications for pain management are to consult the respective physician prior to deciding on the medication that is to be given to the patient. Though it is the primary responsibility of the nurse to undertake a pain assessment, it is the physician who is to be consulted when a patient is to be given a drug that had not been prescribed earlier. This is of more importance when the patient presents to the medical or surgical unit. In the present case, it is a good decision to consult the doctor for pain medication to be given to the patient of 80 years. However, the human error at the nurse’s end relates to the unjustified decision to not recheck the name of the medicine prior to administration. As highlighted by Moorhead et al., (2014) nurses are to ensure that medication errors do not arise by all possible means. This includes rechecking the medicine prior to its administration. Manually ensuring that the correct drug is being administered eliminates chances of errors that might lead to drastic patient outcomes (Nieswiadomy & Bailey, 2017). In addition, the nurse giving hydromorphine in place of morphine should have cleared any confusion arising regarding the two drugs sounding similar. As stated by Braaf et al., (2015) professionalism in nursing is reflected by eliminating all chances of errors and communicating well with other professionals. Clear and transparent communication between the two nurses would have prevented the poor patient outcome.

Medication safety and communication issues were identified that could have eliminated the chances of identifying the incorrect drug administration. In addition, the healthcare setting must have demonstrated an ability to establish, cultivate, nourish and maintain a culture that promotes patient safety. Such a culture need to be sustained as an integral element of organisational functioning that is required for organisational success in mitigating adverse events. In the present context, the recommended actions are to include adequate support for upholding a culture for patient safety.

References

Braaf, S., Rixon, S., Williams, A., Lieu, D., & Manias, E. (2015). Pharmacist-patient medication communication during admission and discharge in specialty hospital settings: implications for person centered healthcare. International Journal of Person Centered Medicine, 4(2), 90-105.

Moorhead, S., Johnson, M., Maas, M. L., & Swanson, E. (2014). Nursing Outcomes Classification (NOC)-E-Book: Measurement of Health Outcomes. Elsevier Health Sciences.

Nieswiadomy, R. M., & Bailey, C. (2017). Foundations of nursing research. Pearson.

Zaccagnini, M., & White, K. (2015). The doctor of nursing practice essentials. Jones & Bartlett Learning.