Question 1
From the case study of Mrs Ellie Smith, it was reported that the patient was 80 years old and she had undergone an open reduction and internal fixation (ORIF) to stabilise the fracture and allow the bones to heal. During her staying in the nursing home, she was prescribed angiotensin converting enzyme (ACE) inhibitors, furosemide, corticosteroids, potassium chloride and an antidepressant (nortriptyline).
The drug furosemide is a loop diuretic drug which helps in the process of increasing the urine output from the body. The drug is also used for treating the edema secondary to various clinical conditions like congestive heart failure exacerbation, renal failure, liver failure, and high blood pressure. As the patients had the problems of oedema, high blood pressure, hence this drug was given to the patient. The drug exerts its action by increasing the elimination of Na+ and water by the kidneys by preventing their reabsorption from the distal and proximal tubules. The bioavailability of the drug followed by the oral administration is approximately 10 per cent to 90 per cent (1).
Potassium chloride is basically used as the electrolyte replenisher and it is mainly used to treat the hypokalaemia condition. The primary reason of depletion potassium in the body is associated with the treatment with diuretics. Considering the situation of the patient, it was reported that the patient had the pitting oedema of the lower limbs and as a consequence the patient was prescribed the furosemide and to maintain the potassium level the potassium chloride was prescribed. However, due to misinterpretation the furosemide was discontinued and continuation of potassium chloride increased potassium level of the body (2).
While discussing about the drug interaction between the ACE inhibitors and the furosemide, it can be reported that the co-admission of the ACE inhibitors along with the furosemide or any other strong Lasix drug is basically safe and along with this it is also reported that the co-admission of these two types of drugs is also effective in nature for the patients. However, it is also very important to mention that in some cases the patients consumed these two drugs simultaneously may develop hypotensive symptoms after the first dose of the drug administration along with the common symptoms like dizziness, fainting and light headedness. Moreover, the symptoms described are mostly observed among the patients who had the issues of chronic diseases such as renal failure and taking the high dose of diuretics along with the ACE inhibitor drugs for the first time (3). These hypotensive conditions can also cause different adverse health consequences such as high level of renin and angiotensin, dehydration, vomiting, haemodialysis, heart failure conditions as well and in this particular case study this condition might happen. Research study also reported that the risk of hypotensive conditions followed by the ACE inhibitor consumption along with the diuretics was enhanced along with the doses of furosemide (more than 80 mg per day) and hence, it is recommended to start the dose of the drug under strict supervision (4).
The drug nortriptyline is used as antidepressant and it exerts its function by preventing the reuptake of norepinephrine and serotonin at neuronal cell membranes. The bioavailability of the drug ranges from 45 per cent to 85 per cent. The main reason of prescribing the drug is associated with the fact that the prolong hospital stay might contribute to the development of depressive symptoms in the patient (5).
Question 2
There are mainly six steps in a basic root cause analysis and they are mainly defining the event, find the causes of the incidents, finding the root cause, finding the solution, taking required actions and the verifying the effectiveness of the proposed solution (6).
As a first step of the root cause analysis, it was reported that the patient had the issue of odema, heart failure and hypertension and for these conditions she was instructed to take various medications. In the hospital transfer form of the patient, furosemide was prescribed along with different other medicines. All medication orders from the transfer form were re-written on the new Medication Administration Record (MAR) however the old MAR from the previous admission was also kept along with the new order. During the rechecking of the MAR, nurse Ayesha interpreted the new Lasix order on the MAR as an unintentional duplication and thus she marked it with yellow. Followed by a phone call, the nurse did not complete the process and after that second nurse Belle completed the double checking and Belle removed the previous MAR and informed Ayesha. Ayesha interpreted that Lasix was removed from the order. Again, on 8th January during the patient care Ayesha was interrupted by the phone call. Suddenly, on the 8th of January at 08.15, the patient had extreme difficulty breathing and the ECG of the patient reported about the sinus tachycardia and peaked T waves. During waiting for the ambulance, the patient had the cardiac arrest and it was reported that Ellie was wrongfully administered potassium chloride. Ellie’s serum potassium level was 7.0 mmol/L (reference range 3.5-4.5 mmol/L).
In the second stage of the RCA, it can be reported that there are a few common causes of the errors caused in the case of Mrs Ellie. The primary causes of this errors were mainly lack of supervision on the nurses, poor management policy of the hospital, absence of the proper electronic health record system in a proper manner.
In the third step, the root causes of the errors can be identified as the lack of the leadership and poor management of the hospital authority. Firstly, a nursing leader must supervise the MAR of the patient considering critical health conditions. Secondly, the nurse should not use mobile phone during the checking of the medical records of a critical patient. Moreover, both of the nurses should also ask about the confusion regarding the order of lasix.
As a part of the solution of the problem, the study findings of a recent study (7), can be mentioned as the researchers mentioned about the nurse leaders’ importance during the checking of the medical records of the critical patients. Secondly, the hospital authority should make policy in a such way so that the nurses cannot use mobile phone during the handling of the patients. The nurses should also be included in the simulation-based training program (8).
In the fifth step, the nurse leader should inform the higher authority about the incident so that such incidents can be prevented. Lastly, it can be reported that the introduction of the simulation-based training program is very much effective as in a study (9), the researchers reported the positive sides of training for improving the awareness of the nurses.
Question 3
The legal aspect of the medicine and drug delivery in the health care setting is regulated by the Federal Supreme Council of the country and along with this, it is also very important to mention that the health care is also regulated at the emirate level of the country. However, more specifically, it can be reported that the administration of drugs including the potassium chloride and antidepressants is controlled by Ministry of Health (MoH), Dubai Health Authority (DHA), Health Authority of Abu Dhabi (HAAD) and Health Ministers’ Council for Gulf Cooperation (GCC). There are a few laws and regulations that are responsible for the controlling of the drug administration in the country. In this regard, it can be reported that the Federal Law No. 4 (1983) is associated with the control activities related to regulation of pharmacy profession, establishments and that of pharmaceutical products (10). Apart from that, Federal Law No. 7 (1975) and Federal Law No. 2 (1996) are also associated with the medication related issues present in the clinics, hospitals and other health care facilities. The MoH is basically responsible for making all the policies, standards and the regulations associated with the health care service delivery including the medication management in the health care setting of the country. These regulations are primarily responsible for the simplification of the federal laws of the country so that the patient compliance, quality of care and better treatment outcomes can be obtained (10).
Question 4
The safe administration of the drugs for the patients is very important in terms of the patient safety as it is directly associated with the health outcomes of the patients. In this context, it is very essential to have proper skills and competencies of the nurses and other health care professionals associated with the medication management and administration (11). In this particular case study, it was reported that the nurse made the mistake as she had taken the phone call during the checking of MAR and for preventing such scenario, the use of the mobile phone during patient handling or medication management should be prohibited. Along with this, the management of the nursing home should arrange training programs for the nurses regarding the Do’s and Don’ts during the administration of the medicines of the patients as well (12). Apart from that, the nurses should be enrolled in the simulation-based environment where the negative impact of wrong drug administration will be shown so that the nurses can prevent themselves from doing any unintentional mistakes during the administration of the drugs in a hospital care setting. Use of the electronic health record can also be recommended to prevent such manual errors by the nurses as electronic health record can prevent such misinterpretation by the nurses observed in this particular case of Mrs Ellie (13).
References
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