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This case is of a 97 years old lady who was already on the verge of perishing, lost her life just one day after she was admitted, due to a medication error committed by the assigned nursing care professional. In this particular case, the life of a geriatric patient was lost to the lack of medication safety in the practice of clinical nursing management. The case study will be discussing whether the patient care was being done following safety measures unbiased of age and gender (ACHQSC, 2017) and if the standard of practice by NMBA (2018) for nursing professionals were followed efficiently. In this write up we are going to discuss whether this incidence was the consequence of simple negligence and the lack of knowledge about the medicine. We would be focusing on a few measures and methods to avoid medication error in medical nursing practice.
Nymphaea Anderson a 97-year-old lady admitted in St George hospital on January 29, 2009, for the complaint of nausea, vomiting, urinary tract infection and dehydration. She had a history of severe heart disease and high blood pressure. She was on both oral and intravenous medicines. She had IV cannula in her right wrist for IV medications. It is stated that on January 30 evening the prognosis of the patient was better. The same evening the nursing staff Ms Lopez started her shift and was the assigned nurse for Mrs Anderson. It is mentioned that since the patient was finding it difficult to swallow three-oral medicine, the nursing staff decided on her instincts to give the medicines together through intravenous route. She crushed all the three oral tablets and mixed them with 10 ml saline and connected it to burette with 100 ml patient fluid and finally connected it with the patient’s right arm cannula. The same night Mrs Andersen died of a severe heart attack at 10:35 pm.
After finding that patient had difficulty in swallowing, Ms Lopez, the responsible nurse for Mrs Anderson went ahead with her own instinct and decided to give all the three oral medicines via IV and not realizing that it is necessary to follow the route of administration strictly as mentioned by a physician. Standard 1 of Nursing and Midwifery Board [NMBA] 2018 stated that the correct route of administration indicated by the physician should be followed. She was lacking the knowledge about the medicine, its adequate route of administration and the adverse consequences which can precipitate in case of malpractice. She did not follow the evidence-based practise before making the decision to change the route of administration for the medicine. Moreover, she did not follow the safe the Australian Commission on Safety and Quality in Health Care, 2017 which demands that the safety of the patient is to be prioritized. It has been concluded in a study that out all the medication error incidence the cases were mostly with the patient of the geriatric population (Phillips et al., 2001). The nursing staff Ms Lopez also failed to follow the rules of adequate communication (ACHQSC, 2017). She failed to transfer the information to the consultant physician about the patient’s difficulty to swallow. Difficulty in swallowing should have been reported with written and verbal communication. This is concluded that she failed to carry out an efficient documentation and effective communication (MacArthur, 2016). The nurse had no insight into the quality care and appropriate documentation. Lack of documentation practice also leads to this situation (Unroe, 2016). The importance of documentation and communication is clearly exhibited in the scenario. If patient details were documented chances of malpractice could have been avoided (Shojania, 2005), A study states that quality of nursing documentation has to be improved for better and effective communication (Törnvall, 2008).
The loss of life of a geriatric patient with a history of high blood pressure and severe heart attack, who was already facing declining health admitted for nausea, vomiting, dehydration was admitted to St George hospital. Next day in the evening her prognosis was estimated to be improving and decision for her discharge was to be finalized. Patient-reported difficulty in swallowing to Ms Lopez. She decided to give three oral medicines via IV, crushed them and mixed with saline and patient body fluid in the burette and connecting to the cannula of IV line of the patient right arm. This resulted in the patient’s death by a severe heart attack. The post-mortem report stated that foreign particle (Binding agent of the medicine) in her blood and pulmonary artery were found.
Due to not following the standard of practice and Australian health safety rules the patient lost her life and Ms Lopez is facing a legal trial against her. This led to all the mental, emotional, financial stress. Her career is destroyed. This Scenario tells that irrespective of the age, gender or disease history and medical status, the nursing care should be done with quality care keeping Australian Commission on Safety and Quality in Health Care in mind. While providing health care it is mandatory to adopt the evidence-based practice. I have also gained the learning that assessment of the patient and new findings should be properly documented by following the rules of documentation. The patient details should be adequately communicated by verbal and written methods. The medication safety has to be followed by increasing the knowledge of medicine, medical history and route of administration should be documented well. To improve nursing practice and to avoid medication errors intelligent use of digitalization should be incorporated (Agrawal, 2009). Use of information and technology for creating safety alerts (Bates et al., 2001). Students should be trained effectively to avoid medical errors and practice safe (Hewitt, Tower, Latimer, 2015).
The learning from this case scenario is that it required to promote safe practice by acquiring strong medical knowledge. It is equally important to follow the standards of practice documented by governing bodies. Evidenced-based practise plays a crucial role to avoid unfavourable incidences while providing medical care. Importance of efficient documentation and communication has been learned from this case scenario. Along with personal losses unsafe medical practice has legal implications as well.
Agrawal, A. (2009). Medication errors: prevention using information technology systems. British journal of clinical pharmacology, 67(6), 681-686.
Australian Commission on Safety and Quality in Health Care. (2017). National safety and quality health service standards (2nd.ed). Retrieved from https://www.safetyandquality.gov.au/our-work/assessment-to-the-nsqhs-standards/nsqhs-standards-second-edition/
Bates, D. W., Cohen, M., Leape, L. L., Overhage, J. M., Shabot, M. M., & Sheridan, T. (2001). Reducing the frequency of errors in medicine using information technology. Journal of the American Medical Informatics Association, 8(4), 299-308.
Hewitt, J., Tower, M., & Latimer, S. (2015). An education intervention to improve nursing students' understanding of medication safety. Nurse education in practice, 15(1), 17-21.
MacArthur, J. (2016). ‘Gaps, mishaps and overlaps’. Nursing documentation: How does it affect care? Journal of Research in Nursing, 21(8), 649-650.
Nursing and Midwifery Board [NMBA]. (2018). Registered Nurses standards for practice. Retrieved from
Phillips, J., Beam, S., Brinker, A., Holquist, C., Honig, P., Lee, L. Y., & Pamer, C. (2001). Retrospective analysis of mortalities associated with medication errors. American Journal of Health-System Pharmacy, 58(19), 1835-1841
Shojania, K. G., & Grimshaw, J. M. (2005). Evidence-based quality improvement: the state of the science. Health affairs, 24(1), 138-150.
Törnvall, E., & Wilhelmsson, S. (2008). Nursing documentation for communicating and evaluating care. Journal of clinical nursing, 17(16), 2116-2124.
Unroe, K. T., Hickman, S. E., Torke, A. M., & Group, A. R. C. W. (2016). Care consistency with documented care preferences: methodologic considerations for implementing the “measuring what matters” quality indicator. Journal of Pain and Symptom Management, 52(4), 453-458.
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