solved

Question
Answered step-by-step
Asked by asjhhumj

Recommendation: Based on the contributing factors or causal factor that were identified, recommend an evidence-based patient safety improvement strategy. What role would patients and families have in the recommendation? 

Contributing Factors identified

There are a variety of contributed factors that lead to the medical error. The first contributing factors that led to the medical error is the preoccupied and bustling state of the nurse while tending for a patient with congestive heart failure. The nurse did not read Ms. Viani’s file. Had the nurse invested time to look at and assess the patient and study the current management, the nurse would not have made the medication error of giving a second dose of Lasix that lowers the client’s potassium level causing disorientation leading to the fall incident. Furthermore, the nurse did not follow hospitalist’s instruction and administered the Lasix IV three hours after patient was hospitalized and blood work to check electrolytes was done before the Lasix IV. The Lasix IV was meant to be given right after patient’s admission followed by a lab test to check electrolytes one hour later. Another contributing factor is the formulation of the assumption by the hospitalist about the lab work up without checking with the rest of the health care team or with the patient when the blood was drawn led to the medication error. Lab should be ordered before the administration of the Lasix. It was a lack of communication among the hospitalist and the nurse. His order is generally accorded respect and without the proper verification, his order may go unchallenged by the assigned nurse. The physician did not review the directive and assumed Lasix IV was given before blood drawn. Mistakenly, ordered a second dose of IV Lasix that led to the incident that the patient experienced. Definitively, both the hospitalist and the nurse had weak communication skills and recordkeeping skills assuming all the instructions were followed in the order were directed. 

Casual Factor identified 

The fact that the nurse was extremely busy at the time of the medical mistake and most likely did not double check her orders for Ms. Viani is one of the casual factors that contributed to the mishap. If she had reviewed the order, she would have known that the blood test to check for electrolytes should have been her top priority, and that she should have administered Lasix subsequently. This should have prevented the administration of the second dose of Lasix and the incident patient experienced.  

 

 

SCIENCE
HEALTH SCIENCE
NURSING
IHP 315