In the book Patient Safety for Health Professionals it states, ’After graduation

Question

In the book Patient Safety for Health Professionals it states, ’After graduation from pharmacy school, I accepted a staff pharmacist position at the hospital where I trained. After completing a 2-week orientation, I came to work on a Monday afternoon to work the evening shift. About an hour before the day shift crew left, the Director of Pharmacy accidentally splashed hydrochloric acid in his eyes. He came across the hall, and we immediately placed his face under the eyewash. He was taken immediately to the emergency department. Needless to say, everyone was pretty shook up about the incident. At 4:00 p.m., the day shift crew left for home, and the evening technician and i began to process the evening orders. We received an order for a “stat” total parenteral nutrition solution (TPN). The surgeon was in the process of placing the central catheter into the patient as a route for administrating the TPN, and nursing sent the order down and called requesting the TPN be compounded (prepared for administration) as soon as possible. The evening technician went home at 7:00 p.m. I reviewed the orders, made the label, and began to compound the TPN. The TPN order included insulin, and I remembered that the only type of insulin that could be used in a TPN was regular insulin. I recall being somewhat concerned about the dose of insulin but decided not to contact the physician because, after all, he was the chief of staff and had much more experience with TPN than I did. After three more calls from nursing asking about their “stat” TPN (stat means “do it immediately”), I completed the compounding, and a nurses aide came to the pharmacy to pick it up. At the end of my shift, I closed down the pharmacy and went home. Even though it was an eventful first day on the job on my own, I felt that i had handled things well. The next morning, the Clinical Pharmacists and the Director of Pharmacy took me into the office and asked me about the TPN. Fortunately, the director had suffered only minor burns to his face from his accident. I recounted how I had compounded the TPN in detail. They asked me how much insulin I added to the TPN. I pulled a copy of the order and told them what I had done. They asked whether I had any concerns about the dose of insulin. I reported that I thought the dose was somewhat high but that I thought that the patient may have been diabetic and the order came from the chief of staff. Then they told me that they physical who had written the order had done so in error. He had intended to write for heparin but had written the order for insulin instead. After the patient became diaphoretic, dizzy, and shaky, the nurse called the physician, and the error was discovered. Fortunately, the patient did not suffer any permanent harm.“

1. What went wrong in this case? Identify each aspect of care that contributed to an error.

2. What can be learned from these specific errors?

3. Can you suggest two system changes that might keep one of these errors from occurring again?

Explanation / Answer

1. Ist thing is that they directly give responsibility to the new employee to prepare TPN, which very wrong because fresher must be escorted by the senior person and as we know that , solution administration is very critical and must be prepared seriously. Secondary is that when pharmacist come to know that there is some doubt to prepare the solution , then he must call the chief to correct it immediately but he didn't do that , and that is the biggest mistake in this paragraph because if he reported then this error must be reversed. Third one is the what to be write and what not must be part of physician as we are in serious profession.

2. We learned that if we come across any doubt we must be clear it before going into the patient body, second is the reporting must be done immediately to avoid harm to patient. Before writing any prescription cross checked must be done by other physician or pharmacist, whether correct written or not. As a fresher employee , first few months must be with senior to learned all things and to become expert.

3. 1st changes is that three sign come on format of prescription that is done by, checked by , and verified by, so that errors is minimises and 2nd changes is that fresher employee must bot be direclty put on to the job.

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