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Case Study- Medication Error
The facts in the case relate to a medication error whereby a patient has received an overdose of
insulin due to an error in reading the prescription from the house physician by the treating nurse.
The patient, an elderly Mrs. Buckman, notes with a lot of concern that the amount of insulin
administered to her by the treating nurse to cover her elevated blood sugar level does not
conform to the amount that she usually receives. Nevertheless, she does not complain to the
treating nurse and allows the nurse to administer the shot of insulin. In the aftermath, she makes
the complaint known to the physician checking on the patients who decides to make a follow up.
As it turns out, the patient had indeed received a major overdose of insulin from the treating
nurse because of an error in reading the prescription. Immediately upon discovering this, the
physician ensures that corrective measures are in place by administering large amounts of
glucose complements to the patient. Additionally, Mrs. Buckman’s blood sugar level is now
monitored every 15minutes for the next two hours to ascertain any changes and respond
appropriately.
The case highlights some management issues which need to be streamlined in order to enhance
smooth running of operations and service delivery. Given that this is a hospital that handles
patients of all sorts, the case reveals areas of hospital management that should be looked into.
Among them is the flow of information between the physicians and the nursing staff. Owing to
the fact that the medication error occurred as a result of information failure between the
physicians and the nurses, this area needs improvement perhaps by automating the information
systems. Another area regards internal controls on prescriptions and medications such that the
nursing department should be free to verify any prescriptions which raise concerns, such as extra
ordinary large amounts of drugs, before administering the same to the patients. Though following orders from the house physician, it’s somewhat unreasonable that the nurse
readily administered such an extraordinary large amount of insulin to an elderly patient without
having second thoughts. In a way, the nurse failed in his duty of care that he owes the patient and
the exercise of ordinary skill and knowledge in her duties.
Most certainly, the nurse should have had second thoughts before deciding to administer the
extra ordinarily large amounts of insulin to a Mrs. Buckman. Given the abnormal levels of the
drug and the fact that it was an elderly in question. It’s also expected that nurse had most
probably administered the drug to other patients previously and thus she knew better. She should
have checked with the doctor in order to be certain on the exact levels. As a matter of fact, if the
patient had not been a keen observer, the situation would have gotten worse.
In all manners of sense, it was very wise of the pharmacist to question the dosage. Although the
pharmacist knew the patient as complaining a lot on almost everything, he was moved by the
complaint on dosage and decided that it was best to inquire and be clear on the exact amount of
dosage administered. It’s quite evident that this inquiry helped to prevent the worst.
This case brings to limelight a situation of information failure in health care management
whereby inaccurate information led to medication error. The mechanisms that should be put in
place to prevent reoccurrence of such cases in future revolve around improving communication
channels and information platforms. The information system in place should be up graded to
relay information in real time. This will ensure faster communication between the nurses,
physicians and doctors on any issues that they may need clarification on. Also,
intercommunication between the nurses and physicians themselves should be encouraged.

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