Then, write 200250 words using the following discussion prompts to guide the content of your initial post. Respond to at least two of your peers posts. Each response needs to have a minimum of 100 words.
Discussion Prompts
- Discuss the nurses role in the outcome of this case study. What nursing factors are relevant to the outcome?
- What factors possibly influenced the nurses error in giving the medication? Explain.
- What steps could the nurse have taken to avoid making the medication error? Explain.
Citation: Gluyas, H. & Morrison, P., (2014). Human factors and medication errors: A case study. Nursing standard (Royal College of Nursing (Great Britain): 1987). Special supplement. 29. 37-42. 10.7748/ns.29.15.37.e9520.
my response:The nurse in the case study was at the middle of a critical medication error at a critical time in her career. Gluyas and Morrison (2014) found that she was a new graduate working her second shift, had not gone through the necessary orientation and was assigned 36 residents and was facing complex communication with external healthcare professionals without proper support. These circumstances led to the development of latent factors that directly led to her active failure at the point of care. According to Rodziewicz et al. (2024), cognitive load is a primary cause of medication errors, especially in novice nurses who are not adequately supervised and have to work with high rates of patients. The nurse incorrectly read a morphine ampoule of 10mg/1mL as 1mg/1mL, and thus drew up 25mg instead of 2.5mg as ordered, an automatic processing error whereby she read what she wanted and not what the label said. The mistake was also overlooked by the extended care assistant who also verified the information automatically and not mindfully. To prevent this mistake, the nurse might have checked a drug reference guide, verified the dose with a competent colleague and employed the three-bucket self-assessment model to identify her increased risk prior to the action. Tariq et al. (2024) highlighted that well-designed verification procedures and robust safety culture are crucial in minimizing medication errors in high-pressure clinical settings.
References
Gluyas, H., & Morrison, P. (2014). Human factors and medication errors: A case study. Nursing Standard, 29(15), 3742.
Rodziewicz, T. L., Houseman, B., Vaqar, S., & Hipskind, J. E. (2024, February 12). Medical error reduction and prevention. StatPearls Publishing.
Tariq, R. A., Vashisht, R., Sinha, A., & Scherbak, Y. (2024, February 12). Medication dispensing errors and prevention. StatPearls Publishing.
peer#1:The nurse played a major role in the outcome of this case because medication administration is a core nursing responsibility. In this situation, the nurse gave the wrong dose of morphine. The nurse gave the patient 25mg instead of 2.5mg, which is a big difference that could cause extreme damage to the body, or even death. This shows how critical accuracy is in nursing care and how this error impacted patient safety. Some nursing factors in this situation include lack of experience, poor clinical judgment, and failure to properly verify the medication dose. The nurse was new and was placed in a high pressure role too quickly, which increased the risk for error.
Several factors influenced the nurses mistake. She was under stress, managing many patients, and dealing with constant interruptions. She also lacked knowledge about morphine dosing and had never administered it before. Also, she misread the medication label and relied on an automatic checking process instead of carefully verifying the dose. These factors can easily lead to errors in clinical settings.
To avoid this error, the nurse could have followed the 6 rights of medication administration more carefully, especially checking the dose and asking a nurse to double-check.
References
Gluyas, H. & Morrison, P., (2014). Human factors and medication errors: A case study. Nursing standard (Royal College of Nursing (Great Britain): 1987). Special supplement. 29. 37-42. 10.7748/ns.29.15.37.e9520
Treas, L. S., Barnett, K. L., & Smith, M. H. (2021). Davis advantage for basic nursing : thinking, doing, and caring. F.A. Davis Company.
peer#2:The nurse played a crucial role in the outcome of this case. The initial error was administering the wrong dose of morphine. The outcome as a whole was not solely because of one person’s negligence. The case shows how nursing is influenced by individual and systemic responsibility. The nurse didn’t catch an incorrect dosage and relied on a double-check with an unlicensed person, directly contributing to the error. Although in the nurse’s defense, she was in a high risk situation with little to no support. Several factors had an impact on the nurses error. She was a newer graduate and only on her second shift with no proper supervision, which contributed to her lack of clinical judgment and medication knowledge. She was responsible for 36 patients, some of which needed high levels of care, which made the workload very overwhelming. Constant interruptions and rush to administer an overdue medication pushed the nurse into cognitive overload. She was not familiar with morphine dosing and incorrectly read the medication label, showing how lack of experience and environmental stressors can really affect decision making. To avoid errors, the nurse could have slowed down several things differently. Most importantly, she should have followed the rights of medication administration carefully, especially when it came to verifying the right dose and concentration. Seeking support from a more experienced nurse would have been extremely helpful, especially given her inexperience. The nurse should have taken a moment to pause despite the pressure of the situation.
Gluyas, H. & Morrison, P., (2014). Human factors and medication errors: A case study. Nursing standard (Royal College of Nursing (Great Britain): 1987). Special supplement. 29. 37-42. 10.7748/ns.29.15.37.e9520.
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