A patient is due to have a PET scan but is claustrophobic s…
This case study highlights a tragic incident involving medication errors and its consequences on patient safety. Medication errors continue to be a significant challenge in healthcare settings, contributing to adverse events, patient harm, and even fatalities. In this case, the nurse intended to administer 2 mg of Versed, a sedative commonly used to manage anxiety, to a patient with claustrophobia before a PET scan. However, due to a series of errors in medication selection and administration, the patient received 2 mg of vecuronium instead, leading to cardiac arrest and death.
One of the contributing factors to this error was the design and functionality of the hospital’s electronic prescribing cabinet. Electronic prescribing cabinets are computerized systems accessed by healthcare professionals to search and retrieve medications for administration to patients. In this case, the nurse attempted to search for Versed but was unable to locate it in the system. As a result, the nurse triggered the “override” feature, which allows access to more potent medications. This override feature, although intended to provide flexibility and facilitate medication retrieval, can also introduce risks by granting access to medications that may have a narrower therapeutic index or higher potential for harm. It is crucial to evaluate the necessity and appropriateness of such override capabilities in medication-related systems to minimize the risk of errors.
Another crucial aspect of this case is the role of technology in medication administration. The nurse, after triggering the override and searching for the medication, selected the first suggestion provided by the system. However, the selected medication was vecuronium, a neuromuscular-blocking agent used for anesthesia induction, rather than Versed. This selection error highlights the need for user-friendly interfaces and effective medication selection algorithms in computerized prescribing systems. Designing intuitive interfaces that promote correct medication selection can significantly reduce the likelihood of errors.
Furthermore, the nurse bypassed the barcode scanning system, an essential safety check for medication administration. Barcode scanning systems are widely used in healthcare settings to ensure correct medication administration by matching the medication barcodes with the patient’s identification band. In this case, the nurse overrides the system and administers vecuronium without scanning the medication barcode, potentially contributing to the administration error. Compliance with barcode scanning procedures and the use of technology-enabled safety checks are crucial in reducing medication errors.
The ultimate consequence of these errors was the patient’s cardiac arrest and subsequent death. Vecuronium, as a neuromuscular-blocking agent, causes paralysis of the muscles, including those required for respiration. Administering vecuronium instead of Versed to a patient who was not under anesthesia would lead to the cessation of breathing, respiratory distress, and ultimately, cardiac arrest. This case emphasizes the critical importance of accurate medication selection and administration to prevent adverse events and patient harm.
To prevent medication errors similar to this case, multiple interventions can be implemented. Firstly, healthcare organizations should carefully evaluate the design, functionality, and safety features of electronic prescribing cabinets and other medication-related systems. The assessment should involve input from healthcare professionals who use these systems and should aim to identify areas for improvement, such as the appropriateness of override capabilities and medication selection algorithms.
Secondly, improving user interfaces and medication selection algorithms can contribute to error reduction. Designing systems that prioritize commonly prescribed medications, provide clear and accurate descriptions, and require minimal manual inputs can support healthcare professionals in selecting the correct medications.
Thirdly, barcode scanning systems should be utilized consistently and appropriately during medication administration. Staff should receive adequate training on the importance of barcode scanning and the potential consequences of bypassing this safety check. Integrating barcode scanning systems with other electronic medication systems, such as electronic prescribing cabinets, can further enhance medication safety.
Finally, healthcare organizations should promote a culture of safety and encourage the reporting and analysis of medication errors. Establishing a blame-free environment where healthcare professionals are encouraged to report errors and near misses can facilitate learning, identify system weaknesses, and drive improvements in medication safety.
In conclusion, this case study demonstrates the impact of medication errors on patient safety. Improving the design and functionality of electronic prescribing systems, enhancing medication selection algorithms and user interfaces, enforcing barcode scanning procedures, and fostering a culture of safety are crucial steps in preventing similar errors and ensuring the safe administration of medications.