Analysis of a medication error
1.Search on line for an article related to a medication error. Search terms can
include medication error cases, medication error case studies, cases of medication errors by nurses, etc. Be sure to choose an article that describes as many details about the case as possible. Try to find one that involves nurses.
Attach the article to the paper when you submit it.
2.Look up the medication or medications involved in a drug reference so you know what they are for, the usual dose, etc. Include that in your paper.
3.Content: In your paper, describe the event as thoroughly as possible:
a. What happened? [Check the 5 rights (right patient, medication, dose, time, route) and documentation, plus allergies, refusal, and patienteducation.] Describe in your own words what happened. Be specific. State the original provider’s order, how it was dispensed, who administered it and how. What was the problem? Describe the patient’s response, and what harm was done. If no harm was done, describe what harm COULD have happened?
b. Where in the chain is the origin of the error?
Identify where the error occurred and with whom. Was it prescribed incorrectly? Dispensed incorrectly? Administered incorrectly? Or was there a known drug interaction or allergy that could have been anticipated?
c.Were there any special circumstances involved? Was there an emergency at the time? Was there short staffing? Was someone distracted?
4.Analysis: Using all of the information above, explain WHY the error occurred, WHY it got as far as it did, and WHAT can be done to stop it.
a.What circumstances contributed to this error?
b.Where in this situation could the error have been stopped? How? What would need to have happened for the error to be prevented?
c.Where in this particular situation would a nurse have been able to intervene to stop a potential error from occurring? (It may be more than one place.)
5.APA Style:
a.The paper should be typed, double-spaced, with a cover sheet and reference page in APA format. (Be sure to reference the original article, the drug reference, and any other sources used.)
