The error that Led to the Death of the Patient
The death of the patient was caused by overdosage. The nurse who was taking care of the patient was “very busy,” and she ended giving the patient a dose of oxycodone which was twenty times stronger than the indicated dose. The patient was supposed to be given thirty milliliters of the medication, but the nurse administered 30 milligrams. The narcotic was too strong for the patient, and it caused his death.
Factors Contributing to the Sentinel Event
The heavy workload is one of the factors responsible for medical errors. The nurse may have had to take care of too many patients in one day which leaves them too tired creating room for making mistakes such as giving the wrong medication to the right error. Errors can also result from nurses being new in a facility, and they have not yet familiarized themselves with how the operations are conducted in the hospital. Untrained and unskilled nurses who are not able to differentiate between the dosage that has been indicated. Such nurses are also not able to go through the medical reports or even write comprehensive reports, and they may end up misleading other nurses. The state of the nurse, example, and the nurse may be too tired because of taking a double shift, and since they are exhausted, they end up making mistakes such as giving excess dosage than indicated (Aspden, Wolcott, Bootman & Cronenwett, 2007). The emotional state of the nurse may result in errors as some of them experience traumatic events when dealing with patients, thus influencing their reasoning.
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Just Culture
It is a culture where the main operators are not implicated by actions, decisions or omissions made but negligence and destructive acts are not tolerated. Errors in medical care have a serious consequence, and they result in system improvements such as reduction of errors and improving patient errors. It can be done by training the nurses so that they can be competent in their operations (Dekker, 2016). Patient safety is improved, for example, by ensuring that the nurses are in their correct state of mind and emotionally stable and are relaxed enough and ready to take care of the patients.
Prevention of Death
An incident report is a form filled out as a way of recording the details that have taken place concerning an unusual event, such as a patient getting injured or dying in a medical institution. The incident reports can be used in preventing the different types of deaths. The incident reports present the way the death took place, such as in the case of giving the excess dosage to patients than it was recommended. The nurses are warned against overdosing their patients, and they are given the medication guide they should use. The reason the nurse committed the error is indicated in the incident event, for example, the nurse who gave the overdose was “very busy.” The nurses will be expected to ensure that when taking of one patient, they pay attention to them only to avoid errors. The incident report provides the implication which resulted from the event, such as the nurse responsible for the issue being laid off work and the institution facing a legal implication. It will be a warning to the medical providers of the implications they may face in case they are irresponsible in their work and ends up committing errors thus preventing a death.
Intervention by Nurse
There are various ways the nurse could have prevented the occurrence of the error that led to the death of the patient. The first approach is ensuring the five rights of medication administration, where the nurse responsible was supposed to follow the institutional policies in relation to medication transcription. The nurse should have confirmed that he was giving the correct dose to the correct patient in the indicated time through the correct route. The second approach was following the proper medication reconciliation procedures (Aspden, Wolcott, Bootman & Cronenwett, 2007). The nurse should have first read the documents of the patients and established the correct dosage he required.
Double checking the procedures during the exchange of the shifts method and consulting with other nurses would have reduced the chances of death. Despite the nurse being very busy, she could have gone through the medical records of the patient and ensured that she established the correct dosage required. Placing zero before a decimal point when recording the medication dosage is the fourth approach. It will avoid confusing between 0.30 and 30 milligrams, and it can cause overdosing like in the case of the patient. The last approach is ensuring that the nurses have a drug guide so that they can learn about the dosages amount and effects it would have on the patient, thus thinking about it before administering the wrong dosage.
If the nurse in the nursing home followed the indicated guidelines, then she would have been careful before administering the wrong dosage. The patient would still be alive and have gone home. The institution would not be facing a possible legal implication.
Reference
Aspden, P., Wolcott, J. A., Bootman, J. L., & Cronenwett, L. R. (2007). Preventing medication errors (pp. 409-46). Washington, DC: National Academies Press.
Dekker, S. (2016). Just culture: Balancing safety and accountability. CRC Press.
