A 56-year-old female with hyperkalemia was in a medical intensive care unit and was ordered to receive sodium polystyrene sulfonate (Kayexalate®) via rectal administration. The nurse caring for this patient inadvertently administered the medication through the urinary(Foley) catheter instead of the rectal tube.The patient developed cystitis because of the error, which required a consult by urology to determine treatment options.
Hicks, R. W., Becker, S. C., & Jackson, D. G. (2008). Understanding medication errors: discussion of a case involving a urinary catheter implicated in a wrong route error. Urologic nursing, 28(6),454-459. Ulku Gunes, R. N., Elcin Efteli, R. N., Burcu Ceylan, R. N., Leyla Baran, R. N., & Ozturk Huri, R. N. (2020). Medication Errors Made by Nursing Students in Turkey. International Journal of Caring Sciences,13(2), 1183-1192.
Q. Reponses to the following:
a. Medication errors lead to rises in healthcare costs and increases in morbidity and mortality rates as well as to serious legal consequences. To promote safe medication use, the Medication Error Taxonomy was introduced as a most comprehensive and standard tool for evaluating medication errors. There are nine harm categories of medication errors in the Medication Error Taxonomy. Research them and identify which harm category this error belongs to. (Note: the Medication Error Taxonomy could be found in the references provided.)
b. Australian Commission on Safety and Quality in Health Care has launched the Safety and Quality Improvement Guide Standard 4: Medication Safety and developed the Medication Management Pathway to manage the safe and effective use of medicines for patients at each episode of care. Referring to this Pathway, identified in which phase of medication management pathway that this error occurred.
c. Which Right of the 12 Rights of medication administration failed to practice in this case?
d. Identify at least 2 possible causes contributing to the medication error in this scenario.
e. Identify three 3 prevention measures including the organisation policy and procedure for addressing medication errors that you can recommend to prevent such occurrences in the future.
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