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Quality and Safety Case Study

Updated August 8, 2022

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Quality and Safety Case Study essay

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Impact of Evidence-Based Practice

In this case study, a nurse mistakenly administers IM Haldol to the wrong patient, and this mistake leads to long-lasting health complications in the patient. The nurse who wrongfully administers the medication works as a medication nurse but still has to perform other functions in treatment and dressing changes. This situation creates an overload of work on the nurse, but her recommendation for the facility to employ a treatment nurse is dismissed due to budget constraints. Additionally, the facility has a regular turnover of staff which makes it impossible for the staff to familiarize themselves with the patients. The drug administration is triggered by a new nursing assistant who informs the nurse that, “sally’s at it again” leading to the administration of sally’s dose to the wrong patient.

There are many potential and actual risks that may occur within a healthcare system. The first one is the risk of medication errors where a healthcare professional may administer the wrong medication to a patient. The second one is the risk of diagnostic error where the symptoms patients’ exhibits may be misdiagnosed; additionally, the diagnosis may be missed entirely or even delayed. The next one is the risk of falls, where a patient may fall leading to injuries or even death. The last class is the risk of potential adverse events which may range from surgical injuries, transfusion errors, wrong-site surgery, and infections related to treatment among others.

The risk of medication errors is the most relevant in this case since the nurse in the case study administers IM Haldol to the wrong patient. An article by Adrian Ghenadenik and others sought to identify the potential risks related to medication administration (Ghenadenik et al, 2012). This article is highly significant on the issue of the risk of medication errors. The authors identify that although medication carts are essential in safely administering medications, they also contribute to the risk of medication errors (Ghenadenik et al, 2012).When the carts are shared by many nurses, it increases the chance for confusion and error in drug administration. Additionally, if not properly locked the carts can easily allow unauthorized individuals to access these medications (Ghenadenik et al, 2012).The article also insists that the Medication Administration Record for each patient should always be brought to the patient’s bed to ensure that the right medication is given to the patient, at the right dosage, to the right patient, at the right time and through the right route (Ghenadenik et al, 2012). Double verification of the patient’s identity is also very important as outlined in the article.

Change and Quality Improvement

The policy that would need to be changed is the hospital policy guiding drug administration as well as the prevention of adverse drug events. Such a policy explains the processes that should be taken when administering drugs to the patients to ensure the Seven Rights of Medication Administration are achieved. Some of the new changes in policy that can be implemented would include, requiring for independent double checks by two healthcare practitioners would reduce the risk of a mistake being made, since it is difficult for two individuals to make the same mistake. Additionally, using more than two identifiers in identifying the patient would also reduce this risk. For example, one can check the patient’s name on the Medical Administration Record (MAR) and ask the patient to say their name plus the date of birth to confirm if it tallies with the information on the MAR.

The change model that would be used will be the Lewin’s Change Model. This model is appropriate since it outlines three essential steps that should be followed in implementing change (Manchester et al, 2014). Firstly, it is important to unfreeze the status quo or the processes currently being followed by the facility to ensure that all staff members see the need for change (Manchester et al, 2014). Next, all possible changes that can be implemented will be considered to decide the most appropriate ones. Lastly, refreezing is done to ensure that the new changes are ingrained into the culture of the facility (Manchester et al, 2014). The best way to empower the staff towards implementing this change is to ensure they are well aware of the change vision and that they are provided with the necessary technology and resources to drive this change (Sales et al, 2016)

Teamwork and Collaboration

From the discussion above, independent double checks and the use of two identifiers in identifying the patient are two change strategies that can be introduced in the new policy. It is, however, important to come up with appropriate ways of communicating this change to the healthcare professionals to ensure they are part of the process. The first way is explaining all steps that will be taken in this change and the contribution required of them (Babiker et al, 2014). Additionally, you must include the benefits that the change will bring in their operations as health professionals, and lastly, the need for this change should be explained honestly to gain their trust.

Teamwork and collaboration are all essential in the implementation of this change. The first way of ensuring effective teamwork and collaboration is making sure all employees work towards the achievement of a shared goal (Babiker et al., 2014). Additionally, each person should possess clear roles that dictate their function in the medication administration process, to avoid confusion due to the performance of conflicting roles (Babiker et al., 2014). Collaboration and effective teamwork only work when there are proper communication channels in place. All members should be able to effectively communicate with each other, as well as raise grievance or give recommendations in the workplace. Lastly, a leader should be in a position to coordinate all the activities of the other members as well as possess skills to resolve conflicts amicably.

Patient-Centered Care

Some best practices can be applied towards making drug administration effective and safe. These practices are:

  •  Ensuring that the healthcare professional administering the drug to patients is kept free from any interruption (Smeulers et al., 2015).
  • Ensuring proper patient verification processes are in place (Smeulers et al, 2015).
  • Categorizing drugs to determine which drugs are high alert medications (Smeulers et al., 2015).

These three best practices can be integrated to promote patient-centered care. Elimination of any interruption points towards prioritizing the patient and his safety first, which is an essential requirement in patient-centered care (Westbrook et al., 2010). A good verification process may include the input of the patient in confirming his identity, and this step helps to involve the patient in the process of providing him with care. Lastly, categorization of drugs helps separate the drugs that pose the most danger to the patient in the case of an error in medication. All the above practices, therefore, work towards the assurance of the patients receiving the best care while protecting him from potential risks (Westbrook et al., 2010).


The lack of informatics played a role in the patient receiving the wrong medication. The evidence is the lack of mention of any technology in the drug administration. The use of a bar-code technology would have prevented the error in medication. This technology is integrated with Bar-Coded Medication Administration (BCMA) systems. This system allows the nurse to scan a barcode on the drug as well as the barcode on the patient’s identification bracelet (Agrawal, 2009). The system ensures there is a match between the medication and the patient and also provides information on the dosage as well as the route of administration, and if the time of administration is correct (Agrawal, 2009). The system reduces all errors that can undermine the achievement of the Seven Rights of Medication Administration.

Synthesis/ Conclusion

Based on the case study some legal and ethical issues arise. The first legal issue the fact that the nurse may be charged with medical negligent that led to a life-long disruption of normal functioning in the patient. The second legal issue is the fact that the patient or her family may choose to sue the hospital and demand compensation for the harm suffered due to the medication error. Some ethical issues may also arise. The patient and healthcare professional bond of trust may be broken making it hard for patients to trust and believe in the interventions introduced by healthcare practitioners. Additionally, if the nurse is punished for the mistake, other nurses may face ethical conflicts on whether to disclose when they realize they have made a medication error. Proper verification of the patients and the application of technology are the best future considerations towards preventing the same occurrence.

Quality and Safety Case Study essay

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Quality and Safety Case Study. (2022, Aug 08). Retrieved from