Question:

Hospital case study - Finding it hard please help. Thank you in advanced?

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A woman with a medical history of epilepsy was hospitalised and commenced on IV fluids for gastrointestinal complications. A jejunostomy was performed to facilitate feeding and administration of oral medications including oral liquid phenytoin. Complications developed and the patient was commenced on total parenteral nutrition. Her orders were changed to IV orders. About two weeks later a nurse who had previously administered oral medications to the patient prepared two IV medications and had these checked.

The nurse then obtained the oral phenytoin liquid, measured 5mL into a cup and then drew it into a syringe. She administered the medications to the patient including the oral phenytoin liquid via central venous catheter (CVC). The patient complained of pain at the injection site and commenced dry retching before losing consciousness. Staff commenced resuscitation but the woman could not be revived.

What you think might be contributing factors to error? Preventions for error?

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3 ANSWERS


  1. bloody murder!


  2. As the previous poster indicated, an oral medication was injected into the blood stream. Oral medications are meant to be absorbed into the blood via the gastrointestinal tract. So the nurse must have thought she/he was injecting into the j-tube.Contributing factors to the error are (1) human error, perhaps also a lack of knowledge to differentiate between a medication intended for a j-tube vs.  CVC, (2) and failure to verify the route/dose that was ordered. Errors like this can be hopefully prevented by closer attention to detail when administering medications.

  3. Right off the bat, injecting an oral medication is bad news.

    The formulations are wildly different-this is stuff that can kill you, and quick!

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