NP 1480
MEDICATION ADMINISTRATION
CASE STUDY ASSIGNMENT
Case Study Instructions:
1.
2.
3.
4.
5.
Read the following two cases.
Choose one of the cases to fulfil the assignment requirements.
Identify the medication error that has occurred.
Identify strategies for preventing the error in future practice.
Identify nursing implications for reporting the error.
Assignment Outline:
1. Introduction including brief overview of the case
2. Body of paper:
a. Identifying the medication error including what potential factors led to the error
b. Strategies for preventing the error in future practice
c. Nursing implications for reporting the error
3. Conclusion
Overall Expectations:
1. Appropriate references for medication error identification, strategies to mitigate, and nursing
implications.
2. Minimum of three scholarly references (current, credible, and applicable)
3. APA 7th edition formatting for citations, references, and headings to be used.
4. Grammar and spelling checked.
5. 3-5 double spaced pages with size 12 Times New Roman font.
Grading Rubric:
Components
Content
(A) Excellent
Correctly
/4 Identifies the
error.
Comprehensive
identification of
strategies of
preventing the
error in future
nursing
practice.
Critical thinking
is
demonstrated
by an in-depth
discussion of
(B) Very Good
(C) Good
(D) Marginal
(F)
Unsatisfactory
Error is
identified.
Clear and
concise
identification of
strategies of
preventing the
error in future
nursing practice
Critical thinking
is
demonstrated
clearly by
discussion
Error is
identified.
Satisfactory
identification of
strategies for
prevention of
error in future.
Critical thinking
is
demonstrated
sometimes by
discussion of
the various
nursing
implications.
Error is
identified.
Vague
identification of
strategies of
preventing
error in future.
Critical thinking
is vague and
weak in
discussion of
nursing
implications.
Does not
provide
identification
the error or
strategies for
preventing the
error in the
future.
Critical thinking
is not
demonstrated
in discussion
the various
nursing
implications.
NP 1480
MEDICATION ADMINISTRATION
the various
nursing
implications.
Presentation & Comprehensive
Organization
introduction
/4 and conclusion.
Excellent
organization of
ideas. All
information is
comprehensive,
clear, and
concise.
nursing
implications.
Clear and
concise
introduction
and conclusion.
Very good
organization of
ideas. Most
information is
clear and
concise.
Satisfactory
introduction
and conclusion.
Ideas
somewhat
organized.
Some
information is
clear, but at
times
superficial.
Spelling &
Grammar
Minimal
grammatical or
spelling errors.
Very good use
of academic
and nursing
language
throughout
paper.
Some
grammatical
and/or spelling
errors.
Satisfactory use
of academic
and nursing
language
throughout
paper.
Most APA
formatting,
referencing,
and citations
accurate.
Very good
variety of
resources used.
Resources are
mostly current,
credible, and
applicable.
No grammatical
or spelling
errors.
/4
Excellent use of
academic and
nursing
language
throughout
paper.
APA
Formatting &
Referencing
/4
Resources
Accurate APA
formatting,
referencing,
and citations.
Excellent
variety of
/4
resources used.
*Minimum of 5 Resources are
all current,
resources*
credible, and
applicable.
Inadequate
introduction
and conclusion
OR fails to
include
introduction or
conclusion.
Clearly lacks
organization of
ideas. Most
information is
superficial and
at times
confusing.
Several
grammatical
and/or spelling
errors.
Inadequate use
of academic
and nursing
language
throughout
paper.
Fails to include
introduction
and conclusion.
Ideas entirely
disorganized
and/or
confusing.
Information is
mostly
confusing
and/or nonexistent.
Some APA
formatting,
referencing,
and citations
errors.
Poor APA
formatting,
referencing,
and citations.
Improper APA
formatting
evident.
Satisfactory
variety of
resources used.
Resources are
mostly current,
credible and/or
applicable.
One resource
Fails to include
or type of
any resources.
resource used.
Resources not
current,
credible, and/or
applicable.
TOTAL =
Copious
grammatical
and/or spelling
errors. Failed to
write paper
using academic
language.
/20 marks x 15 = ___/15%
NP 1480
MEDICATION ADMINISTRATION
Case Study Option 1
Previous medical history:
History of cholecystectomy
Event description:
Laurel Johnson, 56-year-old female, was admitted after having a new onset seizure. She had not been on
medication before and was being started on Klonopin 1mg po qd.
Before the Klonopin had arrived from pharmacy, Laurel’s nurse spent time with Laurel providing
education about the medication. Her nurse then went to the desk to document the education.
While at the desk, Laurel’s nurse took a phone call from a physician who gave a verbal order for another
patient on the unit, Lara Johnstone. The order was for Clonidine 0.1mg po qd for high blood pressure.
The nurse carefully wrote down the order and then read it back to the physician. The medication was
then ordered. When the Clonidine came to the unit from pharmacy, the Health Unit Coordinator took
that medication, along with several others, and placed them on the counter in the medication room.
Another nurse came into the medication room, saw the medications on the counter and placed them in
the bins for the patients.
Laurel’s nurse went into the medication room to set up her medication. She noted what she thought
was an extra dose of Klonopin in Laurel’s bin. She thought because it was a new medication, pharmacy
had mistakenly sent it up twice, once for the initial dose and again for the dose for that day. This often
happened with newly ordered medications which were ordered for once a day. She didn’t think anything
more about it and continued to set up Laurel’s medications according to the medication record. She
then went into Laurel Johnson’s room to give her medication. As she stepped into the room, she asked
the patient to state her name and date of birth. The patient responded, “Laurel Johnson, October 18,
1952”. The nurse then removed the medication from the packaging and gave it to Laurel.
After giving the medication, Laurel’s nurse returned to the medication room to set up the medications
for another patient. She found another nurse searching through the medication bins. When asked what
she was looking for, the nurse said she was looking for her patient Lara Johnstone’s dose of Clonidine. It
was a new dose and she knew it came up from pharmacy as she put it in the patient’s bin herself. The
nurse for Laurel Johnson checked the medication wrapper in her hand from the dose she had just given
Laurel Johnson. She saw that it was the Clonidine with the name Lara Johnstone and birth date
November 18, 1942 clearly stamped on it.
The physician for Laurel Johnson was called and informed of the error. The patient’s vital signs were
ordered to be monitored every hour for two hours then every two hours for four hours. While she had a
slight drop in her blood pressure, she recovered well.
References
Adapted from - Minnesota Department of Health. (2022). Case Study – Medication Error.
https://www.health.state.mn.us/facilities/patientsafety/adverseevents/toolkit/docs/6mederror_casest
udyrev101513.pdf
NP 1480
MEDICATION ADMINISTRATION
Case Study Option 2
Event Description:
Ellie was an 85-year-old resident who was returning to the nursing home on 11/5/21 from the
hospital following a left hip fracture. She had an ORIF done. Prior to her fall, Ellie had been a
resident of the nursing home only a week when she sustained the fracture. She has a history of
congestive heart failure with frequent exacerbations. Admission vital signs were BP 132/76, HR 82,
RR 18.
Ellie’s transfer form from the hospital included an order for Lasix as well as several new
medications. Lasix was part of her original nursing home medication list prior to being transferred to
the hospital. All medication orders from the transfer form were re-written on the new Medication
Administration Record (MAR), but the old MAR from the previous stay was not removed. When the
nurse checked the new orders, she mistakenly interpreted the new Lasix order on the MAR as an
unintentional duplication in transcription and yellowed out the section on the MAR. She was interrupted
to take a phone call and did not complete the process of checking the new orders. She asked another
nurse to complete the process. The second nurse completed double checking the orders and noted
the old MAR was still present. She removed the old MAR and let the first nurse know she had
completed the task.
The nurse who was administering medications noted the section for Lasix had been yellowed out, which
she interpreted to mean the medication was discontinued. She was the same nurse who passed the
medications on the unit for three days in a row. On 11/7/21 the nurse, having interpreted that the
medication was discontinued earlier, removed the Lasix from the medication cart to be sent back to the
pharmacy. It was picked up to return to the pharmacy on 11/8/21.
Ellie was weighed on November 8th with a noted 3 lb. weight increase from admission. The weight
was recorded in her chart with an indication that a call would be placed to Ellie’s physician. No new
orders were recorded following that entry.
On 11/09/21, at 2 a.m., Ellie was noted to be having extreme difficulty breathing. She had +4 pitting
edema, BP was 190/110, HR 120, RR 28. Her lungs were assessed and were moist with crackles
throughout. The attending physician was called. The physician ordered Ellie to be transferred back
to the hospital. While awaiting the ambulance, Ellie went into cardiac arrest and could not be
resuscitated.
References
Adapted from - Minnesota Department of Health. (2022). Case Study – Medication Error.
https://www.health.state.mn.us/facilities/patientsafety/adverseevents/toolkit/docs/scenario_nhmeder
ror..pdf