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Risk Management Case Study: Preventable Medication Errors

By Aida Van Herk, RN, JD, Risk Management AMN Healthcare

Risk Management Case Study: Preventable Medication ErrorsA 55-year old female was transported to the floor after recovering from a surgical procedure. An epidural catheter with morphine was placed for post-operative pain control. Upon arrival, the patient complained of nausea and a headache prompting the on-call physician to prescribe, “Demerol 75mg every three hours for pain.” The preprinted medication orders from anesthesia stated “No narcotics, sedatives, or other respiratory depressants to be given during infusion of epidural medication and for 12 hours after epidural is discontinued except by order of anesthesia.” The nurse had not reviewed this order prior to obtaining and administering the new order for Demerol, a narcotic.

Twenty minutes later, the patient was found unresponsive and aggressive resuscitation efforts were implemented, resulting in intubation and mechanical ventilation of the patient. When brain activity was not found, the family made the decision to take the patient off of life support and the patient died shortly thereafter.

The patient’s family filed a lawsuit claiming negligence in administering the medication. A verdict was entered against the nurse for nearly $4 million.

Lessons to be learned:

Review and verify the MAR. When receiving a patient from another unit, it is critical to review the medication administration record (MAR) and compare it with any medications subsequently ordered to check for discrepancies and/or contraindications. In this case, had the nurse reviewed the MAR prior to administering the newly ordered medication, she would have been alerted to the conflicting order from anesthesia to hold all respiratory depressants, which may have triggered the nurse to withhold the narcotic.

Fulfill your duty. Once a medication order is received from a physician, the medication must be administered safely and appropriately. This means that the nurse must adhere to the “five rights”―ensuring the right patient, right drug, right dosage, right time, and right route―every time a medication is given. In addition, standard nursing practice requires understanding the medication administered. Being familiar with a medication’s indications, safe dosage, possible adverse effects, and contraindications are all crucial in ensuring patient safety. If inexperienced with a particular medication, the nurse should consult the drug guide and/or a physician before administering it. In this case, had there been a better understanding of the medications’ effects on respiratory rate and sedation when administered concurrently with the epidural, the nurse would have recognized that Demerol was unsafe to give under the circumstances.

Be your patients’ advocate, and your own. It is expected that medications are administered in accordance with physician orders and hospital policies and procedures. However, following orders and established procedures alone will not provide protection from liability. If a nurse feels that a medication is not safe for the patient, then it should not be administered. If there is uncertainty or ambiguity about a medication order, seek clarity first―an assumption or guess is too risky. A lack of knowledge about the medication was made worse in this case when the nurse assumed that IV was the correct route in the absence of any indication in the physician’s order. Had the nurse fulfilled her duty by vigilantly taking all of the necessary steps to ensure safe medication administration, she would have likely saved the life of her patient and protected her license.

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