What are the facts in this case? What procedures can be put in place to prevent this from occurring in the future? Should this be considered a sentinel event,* (Links to an external site.)and should a root cause analysis be performed?
Medication Error
You are a physician making rounds on your patients when you arrive at Mrs. Buckman’s room. She’s an elderly lady in her late 70s who recently had colon surgery. She is also the wife of a prominent physician at the hospital. She has been known to be somewhat confrontational with the nursing staff. However, today she states she was just given a shot of insulin to cover her elevated blood sugar and the amount of insulin did not seem to be the usual amount. Even though Mrs. Buckman often complains, you are somewhat concerned about this observation and decide that it would be best to check on this.
You ask the charge nurse to review the dose of insulin given. She, in turn, finds Mrs. Buckman’s nurse, who states that, as ordered, she had given the patient 80 units of insulin. You immediately become quite alarmed, as this is an extraordinarily large dosage. You make sure that the patient is given a large amount of glucose supplement and that her blood sugar is monitored every 15 minutes for the next two hours. To follow up, you also review the chart and note an order from the house physician to give Mrs. Buckman 8.0 units of insulin. You can readily see how this could easily appear to be 80 units.
You meet with the charge nurse, the nursing supervisor, the Director of Nursing, and the treating nurse to determine what can be done to prevent this type of error in the future.
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Discussion Questions
- What are the facts in this case?
- What procedures can be put in place to prevent this from occurring in the future?
- Should this be considered a sentinel event,* (Links to an external site.)and should a root cause analysis be performed?
* Per The Joint Commission (2012), “a sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.”
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