NR 103 Week 5 Small Group Discussion
1. What happened in the incident?
2. Who was involved?
3. What were the ramifications for the patient and/or
... [Show More] staff?
4. Reflect on the incident and think about some causes and possible interventions that could have prevented the error.
Answer
In December 2017, at The Vanderbilt University Medical Center in Nashville, Tennessee a patient that was admitted for subdural hematoma and vision loss died due to medication error. The physician’s order was to give 2 milligrams of Versed, a drug used to treat anxiety, instead, the patient was administered 10 milligrams of Vecuronium, a muscle relaxation used as part of general anesthesia during surgery. This error lead to the death of the patient; nothing was mentioned of the staff, however, the error also put the hospital's Medicare reimbursement in jeopardy with Tennessee Department of Health and Centers for Medicare and Medicaid Services.
Last week, one of the pointers prof. Haynes mentioned was that, “there is no multitasking in nursing”. I assuming the nurse was doing multiple things at once and she picked the wrong medication without realizing it. It’s possible that the medication was for another patient and got room mixed up. Also both medications began with a “V”. The multitasking may be due to the fact that he/she had a lot of responsibilities and was trying to accomplish all, instead of asking for help. He/she could have confirmed the patient’s name, if the patient was unable to respond, the badge could’ve been checked to be sure it was the right patient. Also a colleague could have been asked to verify the medication before giving it to the patient. I truly believe if one of the interventions mentioned above was followed, medication error would not have been the cause of the patient’s death.
Reference
Vanderbilt nurse's error killed a patient, jeopardized Medicare payments
https://www.tennessean.com/story/money/...nurse-killed-patient...death.../2148545002... [Show Less]