Medication Error Case Study in Canada: Causes, Effects, and Prevention

This research examines a medication error case study in Canada, its causes, effects, and prevention strategies. It highlights the importance of strict legislative measures to prevent medication errors.

Running head: NURSING ASSIGNMENT 1
Nursing Assignment
Name:
Institution:
Date:

NURSING ASSIGNMENT 2
Introduction
Administering and prescribing restricted medication is a delicate issue. While the right
medications improve an individual’s mental, physical, emotional and well-being, drugs that are
powerful can pose some serious danger to the patient (PSA Advisories, 2016). When a healthcare
provider administers too little or too much or even administers the wrong medication, the effects
are devastating. In this research, we shall take a look at a serious medication error that happened
in Canada, what effects the error had, how can the state do to prevent these mistakes and also
how the health care providers can do to prevent the errors from happening again, but if they to
occur again, what will the care provider do differently to respond to it.
This medical error case involved a four-year-old who was admitted in Broadview Union
Hospital in Saskatchewan, Canada, on May 14th, 2015, with severe Attention Deficit
Hyperactivity Disorder, where a nurse-administered a wrong dose instead of the one Adam’s
doctor had prescribed to him (Neinstein, 2016). The doctor had prescribed a 0.3 ml liquid dose to
treat the boy’s ADHD, the nurse-administered a 3 ml dose. 30 minutes after the boy was given
the first dosage, he started to act like a slobbering drunk where he couldn’t even stand up as he
was drooling to a point where he had to be carried because he couldn’t walk on his own. The
overdose went unnoticed for months until the boy’s parents decided to report the son’s reaction
to the family doctor and also to get a second opinion at a local clinic. But eventually, the
overdose was discovered after a second visit to the doctor and was immediately corrected. But to
make sure that there was no permanent damage to the boy’s liver and kidney, he was supposed to
be checked by a doctor over a period of five years.

NURSING ASSIGNMENT 3
The factor that led to this error is a dispensing error the wrong dose was administered to
the wrong patient by the nurse as the doctor had prescribed the correct dose to the boy.
Medication errors can cause severe physical injury or even death at times, to the patients, these
preventable mistakes can also severe psychological, emotional, and financial stress to the family
and loved ones as well as the health care providers and the entire health system as a whole (PSA
Advisories, 2015). In this case, it caused Adam a lot of pain to the point where he was not able to
walk and even could have led to a new condition by damaging his kidney or his liver. Also, to
the boy’s family, it caused them a lot of stress trying to figure out Adam’s new condition they
even had to carry him given that he walked on his own before.
The nurse who inadvertently gave Adam the wrong dose suffered from guilt, shame and
self-doubt in a condition known as the “the second victim” where its effects can be life-
threatening as some health care providers can even commit suicide (PSA Advisories, 2016). And
the fact that Adam’s family pursued person injury lawsuit against the nurse for negligence, it will
affect his career advancement and also revoking of his silence. The health care system will spend
a lot of money investigating and modifying policies trying to ensure that such errors do happen
again. Cumulative errors affect the reputation and the re-accreditation of the entire health system
in Canada.
There is no mandatory medical errors disclosure to a public body and also no national
relevant system to monitor how an error like this happens which makes it difficult for the
regulatory bodies to take action on care providers who commit medical errors. This is one of the
political factors that influence medication errors (ISMP Alerts, 2018). Other factors that
contributed to this medication error are the decreasing sense of commitment, inadequate
attention to details because the nurse ought to have noticed the error in the first place. Other

NURSING ASSIGNMENT 4
factors could have been tiredness, confusion, and stress from the care provider. Some economic
factors that led to the error include; lack of skilled and competent healthcare providers, and long
work days clearly influenced this error (ISMP Alerts, 2018). The state should ensure that
healthcare providers employed by the government are highly competent for the job. This is the
first step to preventing much more serious medical errors from happening in the future.
The hospital’s response was systemic as it involved examining Adam to make sure that
the error hadn’t caused any damage to his organs. It also involved shifting from the post-accident
analysis toward designing certain care processes that will help in detecting any more errors (PSA
Advisories, 2017). The national agencies are to hold the nurse accountable for his action by
shifting from blame to punishment to learning how to fix systemic problems through
standardization and simplification procedures and to also reduce over-reliance of the memory.
The national safety organization is addressing this error and many others by employing strategies
that help healthcare providers in primary care to improve patient safety by reducing medication
errors (Quarterwatch Reports, 2018). These strategies include using computer technology,
employing clinical nurses and also through educational programs. These organizations have
introduced a process of documenting and establishing a definitive, consistent list of medications
across care transitions and then rectifying any discrepancies that they come across.
Nurse’s concern about damaging the relationship with the patients is a factor and a major
barrier to the medical error responses. Also, the state is concerned with the damage medical
errors will cause to the entire health system, hence the fear of disclosure. It might also lower the
cost of health which impacts the country’s economy. In order to improve the patients’ safety and
care, the hospital environments should promote communications in all the levels as supporting
care providers (ISMP Alerts, 2018). They should encourage questions on issues concerning

NURSING ASSIGNMENT 5
patients’ safety and should also be allowed to report any medical errors without putting too much
blame on the care providers. This would enhance the value of education in medical residents’
training and also, giving them the opportunity to learn from their colleagues which will improve
quality of care, continuously, through cooperative teamwork (PSA Advisories, 2015). Even
though this does not apply to the medical residents only, it focuses attention to them which may
be a good place to introduce the required change of culture so as to shift the team’s mentality or
the shared accountability and responsibility in healthcare settings.
One of the leadership skills the health care provider should have is by being patient-
centered where he ensures successful patient outcomes through promoting greater nursing
expertise towards the patient. This leadership reduces medical error rates as the care provider
administers the prescribed dose with caution which in turn reduces rates of error deaths. This is
due to the fact that, effective leadership ensures successful clinical outcomes by reducing
medication error rates (PSA Advisories, 2018). If a medical error happens, this time the care
provider should report the error and also giving full explanations to the patients and the families.
The healthcare provider should confront this issue with openness and honesty which will be
critical to building a healthy culture that will encourage continual clinical improvement.
In conclusion, medication errors are preventable and all the health care providers should
ensure a tremendous decline in these errors if they observe the stated role carefully. But in order
to achieve this, strict legislative measures should be put in place to ensure that these measures
are effectively adhered to.
References

NURSING ASSIGNMENT 6
PSA Advisories (2015, September 16). Medication Errors Affecting Pediatric Patients: Unique
Challenges for This Special Population. Retrieved from
https://www.ismp.org/alerts/medication-errors-affecting-pediatric-patients-unique-
challenges-special-population
PSA Advisories. (2015, December 16). Medication Errors Involving Overrides of Healthcare
Technology. Retrieved from https://www.ismp.org/alerts/medication-errors-involving-
overrides-healthcare-technology
PSA Advisories. (2016, March 15). Medication Errors Involving Healthcare Students. Retrieved
from https://www.ismp.org/alerts/medication-errors-involving-healthcare-students
PSA Advisories. (2016, March 27). Oral Anticoagulants: A Review of Common Errors and Risk
Reduction Strategies. Retrieved from https://www.ismp.org/alerts/oral-anticoagulants-
review-common-errors-and-risk-reduction-strategies
PSA Advisories. (2016, September 21). Prescribing Errors that Cause Harm. Retrieved from
https://www.ismp.org/alerts/prescribing-errors-cause-harm
Neinstein, G. (2016, November 22). Medication errors are common across Canada – how
should the healthcare system respond? Retrieved from
https://www.medicalmalpractice.ca/medication-errors-are-common-across-canada-how-
should-the-healthcare-system-respond/
PSA Advisories. (2017, March 15). Medication Errors Attributed to Health Information
Technology. Retrieved from https://www.ismp.org/alerts/medication-errors-attributed-
health-information-technology

NURSING ASSIGNMENT 7
PSA Advisories. (2017, December 20). Medication Errors in Outpatient Hematology and
Oncology Clinics. Retrieved from https://www.ismp.org/alerts/medication-errors-
outpatient-hematology-and-oncology-clinics
ISMP Alerts. (2018, March 24). Cyclosporine Dispensing Errors. Retrieved from
https://www.ismp.org/alerts/cyclosporine-dispensing-errors
ISMP Alerts, I. (2018, April 23). Packaging Could Lead to Acetaminophen Overdoses. Retrieved
from https://www.ismp.org/alerts/misleading-packaging-could-lead-acetaminophen-
overdoses
Quarterwatch reports, (2018, September). Annual Report: Four Feared Adverse Events.
Retrieved from https://www.ismp.org/quarterwatchtm/annual-report-Sept-2018
ISMP Alerts, (2018, September 6). Check for Proper Nucala Dose Preparation. Retrieved from
https://www.ismp.org/alerts/check-proper-nucala-dose-preparation
PSA Advisories. (2018, September 20). The Breakup: Errors when Altering Oral Solid Dosage
Forms. Retrieved from https://www.ismp.org/alerts/breakup-errors-when-altering-oral-
solid-dosage-forms