Controls for Reducing Medication Errors in Healthcare Settings

Running head: ACCOUNTING INFORMATION SYSTEMS
Accounting Information Systems
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1
ACCOUNTING INFORMATION SYSTEMS
Answer 2
The narrative is prepared based on the Quaid-twins incident reported in the California
Health and Human Services Incident Report. The California health care unit had purchased
blood thinner in both pediatric (Hep-Lock) and adult (Heparin) versions that are available in
prepackaged doses. The setting’s pharmacy technicians were responsible for stocking the two
different drugs in different medication cabinets. The vials of the two drugs were similar looking
though one had a dark blue label and the other had a light blue one. The manufacturer of the
drugs had changed the vial of the Hep-Lock drug to red. But the hospital had stocked vials before
the change was made. Unintentionally, vials of Heparin were placed in the pediatric cabinet. The
control to address operational process quality in this case was utilization of different cabinets for
storing drugs prior to their use. Nurses were to retrieve the drugs from the respective cabinets as
per the need of the patient.
The use of such a control measure was ineffective in the present case since the nurse
retrieved incorrect medicine from the pediatric cabinet that is Heparin instead of Hep-Lock,
causing medication error and adverse patient outcome. Medication cabinets are in place for
storing medications as per the different classifications of drugs and scope of use. The purpose is
to store the same in a prudent and controlled manner. Nurses are required to demonstrate clinical
skills in selecting the accurate drug from the cabinet for administering to the patient (Xue et al.
2018).
Answer 3
There is a consensus that the NICU controls were in appropriate in the Quaid-twins case,
leading to medication error and adverse drug reaction. It is thus recommended that other controls