Medication Errors Analysis

Case Facts

The case concerning a patient who was prescribed an unusually large dosage of insulin, 80 instead of 8.0, is a medication mistake issue that requires immediate attention both from staff and leadership. The problem is alarming because the administration of a large insulin dosage can result in nausea, nervousness, dizziness, rapid heartbeat, tremor, seizures, as even coma. There are strategies intended for helping nurses and physicians ensure that the issue never occurs in the future, and it is essential that the personnel pays attention to the issue in the future. Therefore, if the mistake had not been noticed by the patient herself and the staff, the patient could have experienced severe consequences that required emergency intervention.

Management Issues

The lack of clarity on the patient’s information chart, as well as the inability of healthcare professionals to look at the dosage from a critical standpoint and question it, are the key management issues to address. It is unreasonable for the nurse to have given a high dose of insulin because the dose itself should have raised some questions and doubts. However, the nurse did not take a pause to ask for advice from others, nor did they double-check drug information with a doctor. In addition, the pharmacist issuing the dosage of insulin should also have been concerned with the high numbers on the patient chart (Church & Haines, 2016). The overall lack of collaboration and double-checking of information caused the medication mistake while there are clear strategies that could have prevented it.

Overcoming Medication Errors

As to the recommendations and mechanisms to put in place, staff should know the ‘five rights of medication administration,’ including the right patient, the right mediation, the right dose, the right route, and the right time. Besides, it is recommended that professionals who administer medication double-check or sometimes triple check procedures and check with other nurses or physicians whether the information written on patient notes is correct. Besides, they should document all procedures, as well as have a drug guide available for reference for questionable cases (Hewitt et al/, 2015). Patient care and drug administration should be a collaborative process within which staff helps one another to overcome challenging or irregular situations. Besides, medication error reporting has also been considered generally challenging (Rodziewicz & Hipskind, 2020). Such issues as professional compliance, provider protection, and patient protection contribute to gaps in reporting, creating an overall unfavorable environment for addressing medication errors.

Further Considerations

The case may be considered a sentinel event; however, it is imperative that the hospital’s management conducts a root cause analysis to understand the reasons for the error’s occurrence. It is imperative that the healthcare setting establishes procedures for medical error reporting and encourages personnel to learn from previous errors. Information on such errors at the facility can be collected from a variety of resources, ranging from direct observations to the review of patient charts. To ensure that the insulin mistake is a one-off occurrence, the analysis of previous mistakes is necessary. Based on the findings, the management of the facility would make the required adjustments in the practice of the personnel as related to medication administration). Finally, a clearly-defined framework consisting of policies, regulations, and guidelines is fundamental for supporting the work of physicians, nurses, and pharmacists in terms of medication administration.


Church, T., & Haines, S. (2016). Treatment approach to patients with severe insulin resistance. Clinical Diabetes, 34(2), 97-104.

Hewitt, T., Chreim, S., & Forster, A. (2015). Double checking: A second look. Journal of Evaluation in Clinical Practice, 2016, 267-274.

Rodziewicz, T., & Hipskind, J. (2020). Medical error prevention. Web.