The issue that I identified during event review meeting that nurse from Medical/Surgical unit call doctor for 80 years patient for pain medication. Doctor asked the nurse to placed order electronically because he did not have assessed of the computer that specific time. A nurse got telephone order for morphine 2mg intravenous q3hrly. Unfortunately, the nurse gets confused with hydromorphine. A patient accidentally received multiple times an incorrect narcotic drug (hydromorphone instead of morphine), resulting in a fatal result. The nurse, human factors engineering are the core science of patient safety. In analyzing the factors involved in this case, a number of human factors issues were identified throughout the event, as are typically found with other complex catastrophic events. The triggering event, sound-alike drug names, and workplace distraction.
Communication and medication safety process issues were identified, which reduced the likelihood of early discovery of the overdose once the event occurred. The ability of hospital leadership to create, nourish, and to maintain a culture of patient safety is critical to the success of any organizational changes made to mitigate adverse events. Some of the recommended actions contained in this report are designed to assist the hospital to support this desired culture of safety.
Your journal draws from evidence, concepts, and/or theories you have examined in this program, especially those related to your specialization. What have you observed during your Practicum Experience that you would like to analyze through your journal writing?
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