Safety – Medication Administration

A 79 year old dialysis patient was admitted to the ICU after a dialysis session where he experienced severe shortness of breath.  The next day, his doctor prescribed him an antacid after the patient complained of an upset stomach. His nurse instead gave him pancuronium (a paralytic and muscle relaxant).  The drug put him in respiratory arrest.  He remained in a vegetative state until his death one month later.

What happened?

The packaging for pancuronium and the antacid were similar.  The nurse failed to look at the medication and read the packaging, she failed to scan to determine the right medication counts and she failed to match the patient’s ID with the scanned medication.

Here are a few tips on administering medications safely and avoiding harming the patient.

  1. Check the order – make sure the physican’s order is complete and correct. This means it includes the drug’s name, dosage, frequency and route of administration.  If unclear or incomplete, check with the ordering physician before proceeding.
  2. Check the patient – Check the patients name using two methods of identification .
  3. Check the medication – Check the labels and compare with the order. Look for an expiration date and make sure it is not expired.  Check the characteristics of the medication.
  4. Document everything – this includes proper medication labeling and proper recording of administered medication. A lack of proper documentation can result in an error.
  5. Learn the facilities policies – become familiar with the facilities policies, regulations, guidelines and procedures. These policies often contain valuable information regarding the practices of medication ordering, transcribing, administration and documentation.
  6. Know the 5 Rights of Medication Administration


Policy – Peer Review Reminder

TRS Healthcare conducts Two Types of Reviews:

  1. Applicant Peer Reviews are performed on all healthcare professionals with detrimental criteria that may affect quality assurance, patient care and credentialing protocols outcomes during the application and re-application process. Any professional liability actions, credentials failures, civil and criminal actions violating laws and regulations, or violations of TRS policy will result in investigation and documentation of all issues.
  2. Default Peer Reviews are also performed on all clinical, professional or personal incidents that may result in an early termination of assignment by the client, the healthcare professional or TRS.




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