1.1 Medication Errors Focus Problem A 6-year-old patient underwent an outpatient
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1.1 Medication Errors Focus Problem A 6-year-old patient underwent an outpatient tonsillectomy and adenoidectomy. The surgeon ordered 1,000 cc.D5W.dis tion levels. A pharmacist calculated the infusion rate for the IV drip to be administered. He used a calculator and checked his calculations twice. He then listed the infusion rate on the ster pensed at a rate of 600 cc every 8 hours, to maintaih hydrawas the electronic medical chart as 200 mL/hr The nurse who started the infusion obtained a bag of D5W which contains 1,000 cc of fluid, and administered the IV solution to the child. Like other nurses in her unit, she relied on the accuracy of the pharmacist because he had a reputa- tion for correctness. Therefore, she did not check his calcula- tions, even though her job duties included verifying dosages. Once the first 1,000-cc bag of D5W was empty, she hung a second bag to infuse. The child began vomiting frequently, which is not unusual in the recovery for this surgery. The child was given medicine to ease the vomiting. Forty minutes later the child exhibited seizure-like activity, which is unusual in the recovery from this type of sur- gery. This behavior increased over the course of the day, during which a third 1,000-cc bag of D5W was hung to dispense. The pediatrician on call noticed that the patient was experi- encing hyponatremia and water intoxication due to the high IV infusion rate and lack of sodium chloride in the infused medicine. In fact, the child's sodium level was 107 mEg/L whereas the normal range is 136-145 mEq/L. Despite treat- ment, the child did not survive Assuming all three bags were completely administered, how muchD5Wdid the child actuallyreceive compared .he amount ordered? Assuming the surgeon's orders were correct, what should the IV rate have been in cubic centimetersExplanation / Answer
Total 3 bag of D5W contains 3000ml fluid
The volume of ordered fluid is 1800ml/24hr @ 75ml/hr
According the question total 15 hr fluid infused @ 200ml/hr
As per ordered volume of fluid to be infused in 15 hr is 1125ml fluid
Finally patient received the volume of fluid 3000ml instead of 1125ml,total extra volume received 1875ml
Normal sodium level is range from 136-145Meq/L
The actual problem generated by pharmacist but nurse also responsible because each and every medication and fluid must be checked by nurse before infusion
For minimisation the drug error all medication must be checked multiple time at least 3 time before administration
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