Summary
Among the many situations that occur in medical facilities, improper administration of medications is one of the most common. Unfortunately, situations like Julie Thao’s are common due to many factors caused by the harsh conditions of the hospital (Lg15 1, 2012). Not long ago, there was an event that led to the complex physical condition of the patient. A nurse was instructed to administer 10 mcq/kg of epinephrine to a patient prone to asthmatic attacks but miscalculated the dosage and administered a much larger volume of medication. The consequences were high blood pressure and marked tachycardia, and the patient required resuscitation services.
Root Cause Analysis
The staff established the conditions under which the error occurred. First, the nurse was on her second 24-hour shift, so her sleep lasted no more than 4-5 hours, and her fatigue level was high. Second, she had only recently started work after being transferred from another unit, so she was unfamiliar with the available dosage calculation protocols. None of the senior nurses had given her additional instruction or accompanied her through the initial stages. Third, the patient’s medical records were unavailable at the patient’s bedside, and the nurse was not aware of the accompanying instructions. She did not know about patient’s illness, and why they needed epinephrine.
The above conditions suggest several reasons the nurse made a mistake, but the predominant one is the conditions under which she performed her job. The medical facility did not provide her with a convenient shift schedule because there was a staff shortage. It did not prepare the conditions for the new employee’s entry to work and initial follow-up. Finally, the medical staff, did not provide complete information about the patient. The hospital’s inability to prepare conditions for the nurses is the main reason for the accident.
Reference
Lg15 1. (2012). Charged with Manslaughter for a drug error [Video]. YouTube. Web.