Running head: MEDICATION ERROR CASE STUDY 1

Medication Error Case Study

Nathan Eppich

Brigham Young University – Idaho

Nursing 490

Holly Forbush

February 6th, 2019

MEDICATION ERROR CASE STUDY 2

Medication Error Case Study

Summary

The scenario in this case study was about a mix up in patient medications administration.

There were two patients with very similar names and birthdays on same floor. Lara Johnstone,

who received verbal orders for 0.1 mg of Clonidine and Laurel Johnson, who was prescribed 1

mg of Klonipin after having a seizure. When pharmacy came up and delivered multiple

medications for patients on the unit, a nurse took all the medications and separated them into

bins according room numbers. Unfortunately, the medications were still mixed up even though

they were separated into different bins.

Laurel Johnson’s nurse went into the medication room to set up her prescribed

medication. She noted that when she entered the room she thought there was an extra dose of

klonipin in Laurel’s bin. She didn’t think anything of this because when new medication is sent

up by the pharmacy they often send up an extra dose of the prescribed medication. Once

entering Laurel’s room the nurse asked her to state her name and birthday (October 18, 1952).

Once verifying the medication to the patient she proceeded to open it and administer the

prescribed medication.

After administering Laurel Johnson’s medication she headed to the medication room to

prepare another patients medications. Upon entering the room, she finds Lara Johnston’s nurse

searching through the medication bins looking for her patients Clonidine. At that moment

Laurel’s nurse realized that she might have administered the wrong medication to her patient.

She looked at the wrapper in her hand of the medication that she just gave and realized that she

gave Laurel the Clonidine medication that had Lara’s name and birthday on the it (November

18,1952). After realizing that she had given the wrong medication Laurel’s nurse called the
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physician informing him that the wrong medication was given. Orders were given to check the

patient’s vital signs every hour for two hours and then every two hours for four hours. Laurel

had a slight drop in blood pressure but was able to fully recover.

Root Causes

There were a lot of things that went wrong in this scenario allowing this medication error

to occur. The main reason that this error occurred was because similarity of the patients name

and birthday. The nurse thought that she had the right patient since she had previously taken

care of the Laurel and was familiar with her. For this reason the name bands were not checked

leading to the medication error.

Another cause was the system of medication administration. When the nurse separated

the medications into different bins she placed the two patients bins with similar names on top of

each other. Also, neither the charge nurse nor the nurse separating medications gave any

warning of patients with similar names and birthdays. Putting the two bins on top of each other

as well as not informing Laurel’s nurse that there were two patients with similar identifiers

resulted in medication errors occurring.

Lastly, there were a lot of people that were involved with handling Laurels medication

before it was actually administered. The pharmacy sent the medication to the unit floor via the

dummy, the Health Unit Coordinator took the medication, along with several others off the

dummy and placed the on the counter in the medication room. Another nurse came into the

medication room and separated the medications into separate bins for the patients. Shortly after,

Laurel’s nurse came in to get the prescribed medication. The increased number of people

handling the medication as well as the amount of times it was moved opened the door for a

medication error to happen.

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Quality Improvement Plan

Improvement of medication administration in this scenario can be done through

improving the patient identification process. Implementation of an education program reminding

nurses to thoroughly and properly checking name bands for the patients name and birthdays can

establish a positive outcome. Also, another improvement in the hospital setting is to have the

nurse scan wristbands and medication before administering the prescribed medication to ensure

proper safety.

Improving communication between nurses on the unit could have provided a better

outcome. If the Coordinator would have communicated with the nurses letting her know that her

patient’s medications had arrived and that they need to be organized into the appropriate bins, or

that there are two patients with similar names and birthdays that need to be monitored. These

changes in the communication chain could have decreased the possibility of this medication error

of happening.

Clearly the equipment on this unit was a problem. This all started out with a nurse

putting medications for two patient’s with similar names and birthdays in bins that were stacked

on top of each other. If this hospital had a medication dispenser like a PYXIS that forced the

nurses to sign into the dispenser with their identification badge and click on the proper

medication this error could have been prevented. Every unit in a hospital is going to have

distractions that make situations like this harder. Knowing those distractions and learning how to

manage them will decrease medication administration problems.

 MEDICATION ERROR CASE STUDY
Human Factors/
Communication
- The communication between
the doctor, pharmacist, health unit
coordinator, and nurse doing the
medication could have been
better. There was no
communication between the nurse
and the coordinator that took all
the medication room could have
separated the medication and
talked to the nurse letting her
Environment/
Equipment
- There were two different
equipment’s failures that
could focused on two
improve this situation. A
better medication dispenser
like a PYXIS. And secondly a
scanning system to help
decrease medication errors.
Cause and Effect
Diagram
Human Factors/
Training
- Though the nurse had proper
training she did not properly
prepare the medication by
hospital protocol. She also did
not check all 6 rights of
Rules/
Policies/procedures
Rules/Policies/ - The
Procedures
- The nurse didn’t follow the 6
rights of medication
administration when doing
this medication. There is also
a policy that when a name
band become eligible that it
needs to be replaced.
5
Human Factors
Fatigue/ Scheduling
- It stated in the scenario
that the floor was very busy
during the time of the
medication error. But it
didn’t say that the floor was
understaffed nor did it say
she was tired.
Medication Error
Barriers
barrier in this scenario is
that there wasn’t a policy in
place to be sure to check the 6
rights of medication. Joint
Commission National Patient
Safety Goals requires two
identifiers when giving
meds (name & birthday).
This commission also
requires the nurse to read
back the orders to the
physician.
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