NGN Case Study: Medication Administration Walkthrough
Med error scenario, recognition, response, documentation.
Med admin cases test the 5 rights, error recognition, and reporting.
Scenario
Nurse notices warfarin given to patient with INR of 5.5. Order was for 5 mg; 5 mg given.
Recognize
Med given as ordered, but INR significantly elevated. Provider should have held given INR.
Action
Notify provider. Hold subsequent warfarin. Recheck INR. Consider vitamin K if very high. Document objectively.
Reporting
File incident report per facility policy. Patient safety reporting non-punitive. Identify system issue (was INR checked before med pass?).
Frequently asked
Med given as ordered but wrong dose for INR, error?
Yes, system error or provider error. Document factually.
Just-culture model?
Distinguishes human error, at-risk behavior, reckless behavior. Most med errors human error or system failures.
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