Medication Administration Safety Case Summary

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According to the article entitled, “Medication Administration Safety,” medical professional need to recognize the importance of reducing medication errors by, “Improving communication with patients, continually monitoring for errors, proving clinicians with decision-support and information tools, and improving and standardizing medication labeling and drug-related information,” (Hughes). This caused me to question the nurse who was passing the medications who, ‘noted the line for Lasix had been yellowed out.’ Why did she automatically assume this meant the drug was discontinued? Was this the nursing home’s policy to highlight discontinued medications? Furthermore, to continue to get to the root cause of this event, I would ask, why didn’t she verify that the medication was discontinued with another healthcare member? Additional questions I would ask in order to help get to the root cause be, why did the first nurse not finish checking the order for Ellie before passing it off to the second nurse? Also, why did the second nurse take on the task knowing the first nurse had not completed and signed off on the order? And lastly I would ask, why didn’t either one of these two nurses verify whether or not the medication was a misprint? “With inadequate nursing education about patient safety and quality, excessive workload, staffing inadequacies, fatigue, illegible provider handwriting...nurses are continually …show more content…
The fact that this error was overlooked by three different healthcare professionals is baffling to me, but I’m sure events such as this happen all too often. I’ve learned the importance of actively looking for errors, as opposed to just stumbling upon them. Lastly, I’ve learned the importance of working as a healthcare team to insure that every patient receives the best care possible. I believe that in this scenario, had they been working as a team Ellie’s life would’ve been
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