Scenario
You were recently asked to serve on a risk management committee after you completed your MSN. Today your manager has invited you to help with a root cause analysis of an incident in which a medication error occurred. You will present your findings at the risk management committee meeting next week using the Medication Error Report Form and the Root Cause Analysis Summary Form.
Case
A 70-year-old female who was admitted to the coronary intensive care unit for Non-ST Elevation MI (NSTEMI). She has a past medical history of coronary artery disease status post percutaneous intervention (stent): on Plavix (clopidogrel) 75 mg by mouth daily, Toprol XL (metoprolol succinate) 50 mg by mouth daily, hypertension: on losartan 50 mg by mouth daily, and diabetes type 2 on Metformin (glucophage) 1000 mg by mouth twice a day. She has upper and lower dentures, is hard of hearing and wears glasses for vision correction. During this admission, she was prescribed Nitrobid (nitroglycerin ointment) ½ inch every 24 hours applied to the chest wall for chest pain/tightness. Her home blood pressure medication was not initiated; however, her metoprolol 50 mg succinate by mouth daily has been resumed. During the am assessment at 0800, you noticed the patient is hypotensive with systolic blood pressure in the ’80s, heart rate is 76, and oxygen saturation is 96% on 2L. You trend the chart and notice that every morning for the past three days since her admission, she has been hypotensive during the 0800 assessment. Upon further investigation, you notice a tube of nitroglycerin paste on the bedside table lying beside the patient’s denture cup. You further realize that the tube is half empty. You then start to question the patient, for which time she tells you that her denture cream has a funny taste. You inform her that you do not see any denture cream. The patient then points to the Nitrobid (nitroglycerin ointment) and states, “it is right there, and I have been using it for the past three days.” It is at this time that you realize that Ms. Irby has been applying a nitroglycerin paste to her dentures every morning. She has also been receiving the ½ inch Nitrobid (nitroglycerin ointment) to her chest wall every 24 hours.
Instructions
For this deliverable, you will complete three parts and submit two files:
Part 1: Complete the Risk Management Medication Error Form
The Risk Management Medication Error Form will be used to guide the discussion at the Risk Management Committee Meeting. Each medication that the patient is taking should be included on the form to provide a comprehensive background for the committee. Complete and submit this form.
Risk Management Medication Error form
This form requires these components for each of the patient’s medications:
- Name of medication
- Pharmacokinetics of the medication
- Pharmacodynamics of the medication
- Pharmacotherapeutics
- Considerations for the administration of the medication in patients across the lifespan
Part 2: Complete the Root Cause Analysis Summary Form
To guide the discussion at the Risk Management Committee Meeting, complete and submit the
Root Cause Analysis Summary form
The form requires these components:
- Description of the incident that occurred
- Discussion of contributing factors
- Analysis of the root causes
- Recommendations to eliminate the root cause
- Part 3: Create a zip-file
- Submit a zip-file with your completed Risk Management Medication Error Form and Root Cause Analysis Summary Form. Use professional word choice and correct spelling, grammar, and APA style.
