nalyzes an adverse event related to medication errors and evaluates its implications on stakeholders and quality improvement technologies for increasing patient safety.

nalyzes an adverse event related to medication errors and evaluates its implications on stakeholders and quality improvement technologies for increasing patient safety.

Health care organizations and providers have a legal, ethical, and professional mandate of guaranteeing patient safety at all times. Before actual practice, health care providers usually learn the basics of patient safety, strategies for enhancing safety, and implications of unsafe practices. Despite the safety emphasis, adverse and near-miss events often occur in health practice. Medical errors are among the main events, the third cause of deaths and up to 1.1% of hospital admissions in the United States (Schwendimann, 2018). Due to the profound impacts of such events, including permanent injuries and death, it is vital for health care organizations to adopt the necessary intervention strategies to enhance patient safety. This paper analyzes an adverse event related to medication errors and evaluates its implications on stakeholders and quality improvement technologies for increasing patient safety.

Background Information: The Incident

At a neonatal intensive care unit (ICU) at Neo Care Medical Center, the pediatrician nurse reported that a premature baby’s blood glucose level was down at 17.  The situation was not expected since the baby was under Total Parenteral Nutrition (TPN) infusion for over six hours. Multiple bolus doses of dextrose and infusion followed, including a sodium chloride mix, but the hypoglycemia did not change until nurses decided to discontinue TPN. To examine the real cause of the situation since they failed to bring the sugar level up to save the baby, the neonatologist requested the TPN analysis. The infusion contained insulin instead of heparin.

Analysis of the Missed Steps Related to the Adverse Event

ICUs are high-risk operation areas where a small error can cause death. According to Eltaybani et al. (2019), complex care processes such as premature births, advanced health care technologies, and quick therapeutic responses usually complicate processes at ICUs such that the level of medication error is high. To a huge extent, the speed of the operation can trigger an error. However, failure to give the correct infusion was the main cause of the heparin-insulin confusion that led to the baby’s death. At all times, health care providers are advised to do everything possible to prevent adverse events related to medication errors, and this case is a suitable explanation of the severity of the situation.

Several medical management issues led to the medication error. Overdose, labeling problems, and improper drug storage jointlyexacerbated the adverse outcomes in this scenario. In many instances, insulin is taken at 3-4 hour intervals for diabetic patients (Acosta, 2020). Insulin usually comes in a 10 ml vial. Heparin intake is after 8 hours. Like insulin, heparin was also dosed in the care facility at 10 ml little bottles. Both are high-risk medications but were not kept away from each other. The dispensing nurse was also new in the facility, implying that the possibility of confusing the two drugs was very high. Besides the similarity in dosage, heparin and insulin were both stored in an orange and white vial with an orange top. Syringes used for their dosing were also of similar sizes stored in close shelves too.

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As the case illustrates, the nurse missed the right steps in drug confirmation by quickly assuming that she was giving a dose of heparin. She was used to giving heparin stored in the exact quantities and storage containers. The adverse outcome could have been prevented if there were a system process or protocols compelling nurses to confirm the drug before administering it to any patient. Nurses should also be consulting each other when operating in high-risk areas such as in the ICUs. Close monitoring of the patient is highly recommended, unlike in this scenario where nurses waited for six hours to monitor the progress and act.

Similar incidents in other facilities are also common. Acosta (2020) reported that insulin-heparin confusion often occurs due to the similarities in vials, specialized syringes, and administration units. Indeed, the probability of risk is high when heparin and insulin are placed together. Skochelak (2020) further mentioned that heparin dosage instead of insulin usually causes an overdose since the patient is prompted to take heparin at an interval of four hours instead of the usual eight. Treating a patient wrongly using heparin has been a leading cause of bleeding in many patients and damage in the subcutaneous tissue around the stomach. The impacts are profound and costly to patient and families.

Implications on Stakeholders

Adverse events have huge implications on stakeho