In July of 2010 in Miami, Florida, Richard Smith, a 79-year-old dialysis patient was admitted to the ICU after a dialysis appointment left him with severe shortness of breath. The following day after being admitted the patient complained of an upset and the doctor had prescribed him an antacid. Uvo Ologboride, the nurse taking care of Mr. Smith, gave him a deadly dose of a drug called pancuronium, which is a drug that induces paralysis, instead of the antacid. 30 minutes later the patient was found unresponsive, but they were able to revive him. Unfortunately when he was revived, he was left brain dead to which did not settle well with his family. When the patient son had came in he had found his father unconscious, unresponsive, and on a respirator. When looking over the chart to try and figure out what happened it had said his dad had just been resuscitated 10 minutes earlier and the nurse had pretty much told him to go and speak with the doctor. Upon speaking to the doctor he was told the nurse had given his dad the wrong medication which lead to his current state of his condition. The nurse was not able to be reached and spoken to about what happened on that fatal day but from what the doctor had explained was the nurse had grabbed a …show more content…
As well the hospital took extra precautions and removed all pancuronium from the nursing stations except in the operating room, which now can only be handled by the anesthesiologist.
The two of the six rights of medication administration that were violated where the right medication, the right dosage, and the right client. The nurse failed to read the medication order three times before administering the medication, failed to scan for the right count of the medication, and as well failed to match the patient ID with the scanned
While working at the OB-GYN department in the hospital, Dr. Vandall, as a Vice Chair of the Department of Obstetrics and Gynecology, learned that another employee of the hospital, Dr. Margaret Nordell was engaged in a level of treatment that was unethical and violated accepted standards of care. It was his duty to the hospital and to the patients, to monitor the competence of his staff members. Although he tried to take the proper steps to deal with it within the hospital, he ended up reporting this to the North Dakota Board of Medical Examiners. It was concluded by the Board that the treatment of Dr. Nordell was gross negligence and they suspended her license to practice medicine.
Jahi McMath is a 13-year-old girl living in Oakland, CA who was declared brain dead by multiple neurologists more than three months ago. Jahi was declared brain-dead December 12th after barriers during surgery a few days earlier to remove her tonsils, adenoids, and uvula at Children's Hospital & Research Center Oakland. At least three neurologists confirmed that Jahi was unable to breathe on her own, had no blood flow to her brain, and had no sign of electrical activity in her brain. Moreover, a court order kept Jahi's body on a ventilator while independent experts could be brought in to confirm the results (Wells, 2014). Even so, the McMath family was able to secure the release of Jahi's body through the county coroner, who issued a death certificate, and have been keeping her on a ventilator at an undisclosed facility ever since. This all occurred after Children’s Hospital released Jahi due to her severe brain damage along with the probability of the hospital receiving profit from discharging Jahi before her or her family were ready for her to be released (Johnson and Rhodes, 2010, p. 61).
4). Examples of how nurses can integrate this competency include; using current practice guidelines and researching into hospital’s policies (Jurado, 2015). According to Sherwood & Zomorodi (2014) nurses should use current evidence based standards when providing care to patients. Nurse B violated one of the rights of medication administration. South Florida State Hospital does not use ID wristbands; instead they use a picture of the patient in the medication cup. Nurse B did not ask the patient to confirm his name in order to verify this information with the picture in the computer. By omitting this step in the process of medication administration, nurse B put the patient at risk of a medication error, which could have caused a negative patient
In this case we are presented with Dr. Marshall Westood who was sitting down for dinner that consisted of pufferfish and rice. Within an hour of eating his meal Dr. Marshall Westwood felt numbness to his lips and tongue, which quickly spread to his face and neck. The symptoms increasingly got worse as he began to feel pain in his stomach and throat that lead to severe vomiting. He was soon after rushed to the hospital. On the way there he experienced difficulty breathing and health care workers had to maintain a patent airway. At this point Dr. Marshal Westwood was experiencing paralysis to the upper body that included the face and the neck. His vital signs showed that he was having an irregular heartbeat. When admitted to the hospital he was given activated charcoal which helped absorbed any remnants of chemicals still present in his stomach. Within a few hours, Dr. Marshall Westwood ‘s symptoms were subsiding and his condition improved.
...estions if not 100% sure of something or use a double checking system. When a nurse is administrating medication, they should use the ten rights of medication administration (right patient, right drug, right route, right time, right dose, right documentation, right action, right form, right response, and right to refuse). Nurses should always keep good hand hygiene and always wear appropriate clothing to prevent from the spread of disease. Good communication with patients and healthcare team members is also key to success. Keeping on the eye on the patient within an appropriate time is important. If the patient ever seems to be looking different than their usual self vitals should be taken immediately. Encouraging patients to ask questions if they are unaware of something can prevent errors as well. Nurses should make sure the patient is on the same page as they are.
Medication Errors one of the biggest issues happening in an acute care setting today . Although, Medications are given based on the five rights principles: the right patient, right medication, right route, right dose, and right time. Even with the five rights principles medication errors are still happening. However, some of the errors that are occurring are due to poor order transcriptions and documentation, drug interactions, proper drug name and not paying enough attention and environment factors.
The main quality initiative affected by this workaround is patient safety. The hospital switched to computer medication administration as opposed to paper medication administration documentation because it is supposed to be safer. So, when the nurse gets the “wrong medication” message the computer thinks something is wrong, this is a safety net that is built into the computer system. If the nurse were just to administer the medication without any further checks, he or she would be putting patient safety on the line. The policy involved that pertains to this workaround is the “8 rights of medication administration”, which are: right patient, right medication, right dose, right route, right time, right documentation, right reason, and right response (LippincottNursingCenter®, 2011). Each nurse it taught these eight rights of medication administration in nursing school, therefore it is a nursing policy. When this workaround occurs the nurse should use his/her judgment before “scan overriding” and ensure these eight checks before administering the
The patient is a 78-year-old gentleman who is brought to the emergency room because of increasing confusion. Evidently the daughter has taken to the bank to get some money when the daughter try to assist him to put his money in his pocket he became aggressive and combative and began to swing at her with his cane and then walked off. She was the unable to find for approximately 4 hours. When he was found he was brought to the emergency room. In the emergency room the patient was placed initially in observation status. Despite being treated in observation with fluids he remained confused and somewhat aggressive and it was determined that the patient required acute inpatient hospitalization. His medical history is significant for hypertension,
Emilio is terminally ill and is under the care of the Children’s Hospital in Texas. He is placed on life support by a respirator and is given pills causing the child to spend majority of his time in the pediatric intensive care unit unconscious. Showing no signs of improvement, the physician has requested the parents look for another hospital willing to continue aiding Emilio within a period of 10 days. Under the Texas “futile-care” law, the hospital’s ethics committee can, “declare the care of a terminally ill patient to be of no benefit,” allowing them to terminate care after a given time period. (Moreno, Sylvia. Case Puts Futile-Treatment Law Under a Microscope.
The Lewis Blackman Case: Ethics, Law, and Implications for the Future Medical errors in decision making that result in harm or death are tragic and costly to the families affected. There are also negative impacts to the medical providers and the associated institutions (Wu, 2000). Patient safety is a cornerstone of higher-quality health care and nurses serve as a communication link in all settings which is critical in surveillance and coordination to reduce adverse outcomes (Mitchell, 2008). The Lewis Blackman Case 1 of 1 point accrued
Drug administration forms a major part of the clinical nurse’s role. Medicines are prescribed by the doctor and dispensed by the pharmacist but responsibility for correct administration rests with the registered nurse (O'Shea 1999). So as a student nurse this has become my duty and something that I need to practice and become competent in carrying it out. Each registered nurse is accountable for his/her practice. This practice includes preparing, checking and administering medications, updating knowledge of medications, monitoring the effectiveness of treatment, reporting adverse drug reactions and teaching patients about the drugs that they receive (NMC 2008). Accountability also goes for students, if at any point I felt I was not competent enough to dispensing a certain drug it would be my responsibility in speaking up and let the registered nurses know, so that I could shadow them and have the opportunity to learn help me in future practice and administration.
I had an elderly patient that was admitted with broken heart syndrome, due to her husband of sixty years passing the recent month. The family of this patient wanted to fly her to a different state to be close to family; with her husband passing she no longer had family here to help her. This patient’s health started to decline during her admission to the hospital and she was found to have possible gall stones and cholecystitis. On the last evening that I had her she was in a great amount of pain and was getting agitated and restless; due to this the family requested that I give her Ativan, with her NPO status I had to give the Ativan through IM injection. Through the night she declined progressively and went unresponsive, I made multiple phone calls to the physicians and to our rapid response nurses in hopes that I could help her in some way; they all kept telling me that she was unresponsive due to the Ativan and to give it time to wear off. After morning labs were drawn I was called with a critical WBC count of 38 that was up from 11 the day before, I followed protocol and called the physician on call and was told she was already on antibiotics and there was nothing else we could do. At the end of my shift I gave report to the oncoming nurse and left and thought about this patient all day. I found out later that this patient was sent to the ICU that day and later passed away that week. For me this was a very difficult situation, I assessed and reassessed, I advocated, and gave care to the best of my abilities but no one wanted to listen to me that this patient was deteriorating quickly and in the end she died from it. Now I try to look at this as her getting to go be with her husband, but this could have gone a completely different way. Although we follow our scope of practice as a nurse we may not always get the end results that we hope for,
Thank you, Amy, for your post! The five rights of medication administration are helpful tools for helping us to medicate our patients safely. If we, nurses, follow these simple rules it will help tremendously in reducing errors. Unfortunately, some nurses use shortcuts and rush thru the process. The hospital that I work at not only teach us to compare the ID band with the name and date of Birth but we should also ask the patients to state their full name and date of birth to make sure the patient has the right ID band. Some patients will get upset with the nurse and explained that they are tired of repeating the same thing all day. When this happened, I usually explained to them that we go thru all these steps to prevent giving them the wrong
Joan Jutting, the district's nurse manager, sent a letter to the grandfather admitting a mistake in the Five Rights For Medication Administration happened, saying changes would be made. The list of policies that would be followed included:
Imagine you or one of your family members being in a persistent vegetative state, a conduction in which a medical patient is completely unresponsive to physical and psychological stimuli and shows no sign of high brain function, being kept alive only by medical intervention. That would be more than difficult to imagine, but for the Cruzan’s family it was a reality. Nancy Cruzan was in a car accident, which resulted in massive injuries. Nancy was in an unconscious state and very unresponsive in daily activities. She was in a vegetable state with an implanted feeding tube in her stomach. As years passed by the family decided they wanted the feeding tube to be removed in order for Nancy to get the peace she needed. The Supreme Court didn’t quite agree with the family’s decision of removal of the feeding tube. The Supreme Court seized the family’s upright decision to remove the feeding tube from Nancy Cruzan because her family knows what is better for her rather than someone who knows almost nothing about her.