Drugs Security And Blunder Avoidance Discussion Paper
A nurse is working in a busy, crowded emergency department. He is instructed by the doctor to get a vial of heparin flush for a patient, but retrieves potassium as the vials are almost identical. The patient screams with pain when they are injected. The nurse feels terrible and afraid they will be fired.
- Describe background factors that may have contributed to this error
- What steps would you take to address this error
- Describe strategies to prevent this error from occurring again
This solution was written by a subject matter expert. It’s designed to help students like you learn core concepts.
Foundation factors that might have added to this blunder:
Absence of separation between heparin flush and potassium vials: The vials of heparin flush and potassium might look practically the same and have comparative bundling, which could make it simple to befuddle them.
High responsibility and stress: Working in an occupied and swarmed crisis office can be overpowering and upsetting, which could affect a medical caretaker’s capacity to give close consideration to detail.
Absence of normalized conventions: There may not be clear and normalized conventions for recovering and directing meds, which could prompt disarray and blunders.
Moves toward address this mistake: Drugs Security And Blunder Avoidance Discussion Paper
Quickly recognize and apologize for the mistake to the patient and some other pertinent gatherings included.
Report the blunder to the doctor in control and archive the episode in the patient’s clinical record.
Partake in a main driver examination with the medical care group to decide the fundamental factors that added to the mistake and distinguish potential open doors for development.
Do whatever it may take to address any private factors that might have added to the mistake, like pressure, exhaustion, or interruption.
Procedures to keep this mistake from happening once more:
Carry out prescription security conventions that incorporate clear naming, stockpiling, and treatment of drugs, as well as standard working systems for directing meds.
Direct standard preparation and training for medical services suppliers taking drugs security and blunder avoidance.
Carry out innovation arrangements, for example, standardized identification checking and electronic medicine organization records, to assist with decreasing mistakes.
Support a culture of open correspondence and revealing of blunders, with the goal that medical services suppliers can gain from missteps and do whatever it may take to forestall comparable mistakes from now on. Drugs Security And Blunder Avoidance Discussion Paper