1..The narrative is prepared based on the Quaid-twins incident reported in the California Health and Human Services Incident Report. The California health care unit had purchased blood thinner in both pediatric (Hep-Lock) and adult (Heparin) versions that are available in prepackaged doses. The setting’s pharmacy technicians were responsible for stocking the two different drugs in different medication cabinets. The vials of the two drugs were similar looking though one had a dark blue label and the other had a light blue one. The manufacturer of the drugs had changed the vial of the Hep-Lock drug to red. But the hospital had stocked vials before the change was made. Unintentionally, vials of Heparin were placed in the pediatric cabinet. The control to address operational process quality in this case was utilization of different cabinets for storing drugs prior to their use. Nurses were to retrieve the drugs from the respective cabinets as per the need of the patient.
The use of such a control measure was ineffective in the present case since the nurse retrieved incorrect medicine from the pediatric cabinet that is Heparin instead of Hep-Lock, causing medication error and adverse patient outcome. Medication cabinets are in place for storing medications as per the different classifications of drugs and scope of use. The purpose is to store the same in a prudent and controlled manner. Nurses are required to demonstrate clinical skills in selecting the accurate drug from the cabinet for administering to the patient (Xue et al. 2018).
2.There is a consensus that the NICU controls were in appropriate in the Quaid-twins case, leading to medication error and adverse drug reaction. It is thus recommended that other controls are required for reducing the chance of such incidents. The first control that could be employed is Automated Medication Dispensing. Such a technology based intervention would be a proper mechanism for improving medication distribution. The mechanism of the technology is based on a computer interface between the hospital pharmacy computer terminals and the dispensing machines at the wards. The system would enable electronic control and tracking of dispensing of unit doses for the patient as per the individualized need. The dispensing machines would permit storage of medicines on the respective ward and staffs would access them conveniently (Zgarrick, et al.). Automate dispensing machines are responsible for providing secured medication storage on care units and clinical staff’s nursing time is saved by eliminating the requirement of manual medicine procurement. As cabinet design and utilization is under much debate for optimal potential, automated dispensing machines are a great step towards patient safety (Paradis and Jacques-Bernard Gauthier).
The second control measure would be provision for patient medication profile. Such profiles are useful in cases where the hospital pharmacists are to monitor inpatient medication therapy. The profiles are to contain data on the pharmaceutical therapy for each patient. It has been noted that such profiles give best benefits when used in conjunction with automated dispensing systems. The pharmacist in this case reviews all the medication of a patient prior to dispensing the doses as per the order. Computerized systems allow the display of the medication profile on the screen that the pharmacist can refer (Jensen et al.).
Jensen, Thomas Bo, et al. "Content and validation of the Electronic Patient Medication module (EPM)—the administrative in-hospital drug use database in the Capital Region of Denmark." Scandinavian journal of public health (2018): 1403494818760050.
Paradis, Johanne, and Jacques-Bernard Gauthier. "Theoretical foundations of hospital pharmacy management." (2016).
Xue, Chengbin, et al. "Home Medication Cabinets and Medication Taking Behavior of the Staffs in a University in China." IOP Conference Series: Materials Science and Engineering. Vol. 301. No. 1. IOP Publishing, (2018).
Zgarrick, D. P., et al. "Pharmacy Management: Essentials for All Practice Settings, 4e." (2016).