A nurse has administered the wrong medication to a patient. In investigating the root cause of the error, it is discovered that the nurse was unfamiliar with the medication and that the Pyxis was incorrectly loaded with the wrong medication.
What should be the outcome of this process?
a. The nurse should be educated on this medication.
b. Pharmacy should develop a second check of medications prior to loading in the Pyxis.
c. The nurse will not be allowed to pass medications without supervision until deemed safe.
d. An incident report will be completed.
Question 2
A unit secretary mistakenly enters the wrong medication into the MAR when transcribing orders. After a root cause analysis, it is determined that the cause is the illegibility of the physician's or-der.
Which measure should be taken to prevent future incidences?
a. The physician is required to carry a type-writer with him to type the orders onto the order sheet.
b. The physician must either write legibly or orders will not be transcribed.
c. The unit secretary must receive more training on transcribing orders.
d. Introduction of a computer entry system for all physician orders will be instituted.
Bowman's Root
Patient teaching: neck assessment
Assisting a falling patient.
National Patient Safety Goals for Acute-Care Hospitals