Analysis of a medication error

1.​Search on line for an article related to a medication error.  Search terms can
​include medication error cases, medication error case studies, cases of ​medication errors by nurses, etc. Be sure to choose an article that describes as ​many details about the case as possible. Try to find one that involves nurses.
​Attach the article to the paper when you submit it.
2.​Look up the medication or medications involved in a drug reference so you ​know what they are for, the usual dose, etc. Include that in your paper.
3.​Content: In your paper, describe the event as thoroughly as possible:
​a.  ​What happened?  [Check the 5 rights (right patient, medication, dose, ​​time, route) and documentation, plus allergies, refusal, and patient​​​education.]  Describe in your own words what happened.  Be specific. ​​​State the original provider’s order, how it was dispensed, who ​​​​administered it and how.  What was the problem? Describe the ​​​​patient’s response, and what harm was done. If no harm was done, ​​​describe what harm COULD have happened?
​b. ​Where in the chain is the origin of the error?
​​Identify where the error occurred and with whom.  Was it prescribed ​​​incorrectly? Dispensed incorrectly? Administered incorrectly? Or was ​​​there a known drug interaction or allergy that could have been ​​​​anticipated?
​c.​Were there any special circumstances involved? Was there an ​​​emergency at the time? Was there short staffing? Was someone ​​​distracted?
4.​Analysis: Using all of the information above, explain WHY the error ​occurred, WHY it got as far as it did, and WHAT can be done to stop it.
​a.​What circumstances contributed to this error?
​b.​Where in this situation could the error have been stopped? How? ​​​What would need to have happened for the error to be prevented?
​c.​Where in this particular situation would a nurse have been able to ​​​intervene to stop a potential error from occurring? (It may be more ​​​than one place.)
5.​APA Style:
​a.​The paper should be typed, double-spaced, with a cover sheet and ​​​reference page in APA format.  (Be sure to reference the original ​​​article, the drug reference, and any other sources used.)

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