Case Study Presentation Question & Answer Guide (With Explanation)

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Original Question

NURS423 Case Study Presentation Medication Errors on a Medical-Surgical Unit Background A medication error is defined as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer” (FDA, 2019). Medication errors can occur anywhere in the health care system; Such as, when a drug is prescribed, when entering information into a computer system, when the drug is being prepared or dispensed, or when the drug is given to or taken by a patient. A medication error may result in minor discomfort or side effects, or something much more harmful. Serious harmful results of a medication error may include illness or injury, adverse reactions, hospitalization, disability, birth defects, life threatening situations, or death (FDA, 2019). The FDA looks for ways to prevent medication errors. Before drugs are approved for marketing, drug name, labeling, packaging, and product design are carefully reviewed to identify and revise any information that may contribute to a medication error. After drugs are approved for marketing in the United States, FDA monitors and evaluates medication error reports, receiving more than 100,000 such reports annually. If needed, FDA may require a manufacturer to revise the labeling, packaging, product design or proprietary name to prevent error. In addition, FDA may also issue communications alerting the public about a medication error safety risk (FDA, 2019). The FDA also established rules requiring barcodes on certain drug and biological product labels. Barcodes allow professionals to use barcode scanning equipment to verify that the right drug — in the right dose and right route of administration — is being given to the right patient at the right time. This system is intended to help reduce the number of medication errors that occur in hospitals and other healthcare settings. Scenario Helen was admitted to the hospital recently for an exacerbation of COPD. She is 82 years old, and her memory has been failing lately, so her husband, Jim, has overseen the dispensing of her at-home mediations. In addition to COPD, Helen has had issues with high blood pressure and pedal edema. Along with her daily inhalers for COPD, Helen has been prescribed Zestril and Lasix at home. In the hospital, all of Helen’s meds were continued. At one of his daily visits to the hospital, Jim noticed that Helen had begun to have mild pedal edema. Knowing that this had been a problem in the past, he was concerned. So the next day, he brought her meds from home and gave them to her, without saying anything to the nurse. This went on for several days, and Helen experienced a significant drop in her blood pressure and became increasingly weak. One day, one of the CNAs entered the room when Jim was giving Helen the meds. She did not report it to the nurse right away. She forgot to do so that day, but she did mention it when she came back for her shift 2 days later. When questioned, Jim said he understood that Helen was on lisinopril and furosemide in the hospital. He did not, however, realize that Zestril was the same as lisinopril, and Lasix was the same as furosemide. Once the error was discovered, Jim did not give any more meds to Helen, her meds were adjusted, and her condition improved. Further investigation revealed that Helen had been admitted through the E.R. and not a direct admission to the unit; and that she was admitted right at the time of shift change. The normal admission routine had not been followed, and some important teaching had been overlooked. Helen was fortunate that she did not experience more serious consequences related to this medication error. She recovered quickly and was discharged to home and instructed to follow up with her PCP. References Working to reduce medication errors. U. S. Food and Drug Administration (2019). Retrieved March 4, 2022, from https://www.fda.gov/drugs/information-consumers-and-patientsdrugs/working-reduce-medication-errors Instructions for Presentation Using the Donabedian Model, identify the following Three aspects of Structure (S) Three aspects of Process (P) Two measurable Outcomes (O) Identify the following factors related to S and P: Accessibility Technical/Material Interpersonal Continuity Identify the Balancing Factors that may affect your S, P, or O. As the nurse leading this quality assessment and improvement project, what would be your first step in the process? (PPT slide #4) What tools will you use to measure the outcome? (PPT slide #5) Who are the stakeholders affected by this quality issue? (PPT slide #6) How will you utilize Ways of Knowing to implement change? (PPT slide #7) Include any references used in your presentation (PPT slide #8)

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