This case study was made available to MIEC through our partnership with CRICO. It was written by Kathy Zigmont, BS, RN, CPPS Description A 61-year-old female with a complex medical history died after being administered contraindicated medications. Clinical Events A 61-year-old female with a complicated medical history was admitted for an evaluation of a large right ventricular thrombus with Automatic Implantable Cardioverter Defibrillator (AICD) lead involvement. Her history included non-ischemic cardiomyopathy with ventricular tachycardia, an AICD placement, atrial fibrillation, and recurrent pulmonary emboli. The patient was also taking the antiarrhythmic Dofetilide (500mcg/day), which is associated with QT interval prolongation, a...
This case study was put together by our partners at CRICO and was written by Jennifer Vuu Sanchez, CRICO A 30-year-old female underwent an emergency cesarean delivery after receiving incorrect medication during her labor. Key Lessons Completing the five rights of medication administration can reduce medication errors Review systems errors related to medication administration Clinical Sequence Close to the time of a change of shift, a 30-year-old female primigravida presented to the Labor and Delivery (L&D) unit and was assigned to a registered nurse (RN). This RN had less than two years of nursing experience and had been working on...
Failure to Double-check Blood-product Dosing Imperils Tonsillectomy Patient
This case study was made available to MIEC through our partnership with CRICO. It was written by Barbara Szeidler, RN, BS, LNC, CPHQ, CPPS, CRICO Description An 8-year-old girl experienced a tenfold dosing error of clotting factor requiring admission and post-operative observation due to increased risk of stroke following surgical intervention for a post-tonsillectomy complication. Key Lessons Fatigue can have consequence during medication/blood product administration. Verbal orders should only be used in emergent situations; when used, incorporate read back/feedback. Products released from the blood bank may not be subject to the same dispensing/oversight processes as pharmacy-dispensed medications. Product was administered...