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

Running head: NURSING ASSIGNMENT 1
Nursing Assignment
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Institution:
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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