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Medication errors by a nurse happen every day. In fact, adverse drug events account for almost 700,000 ER visits and 100,000 hospitalizations every year. In many cases, these errors can lead to medical malpractice claims made against individual practitioners or even against entire health care teams. The majority of medication errors are preventable, and knowing how they happen can teach you what to be aware as future nurses.

These five real-life medication error case studies that involved nurses. While these stories can be hard to read, they are also important reminders of just how easy it can be to make errors with patients' medications, even if when you are a highly experienced and skilled nurse. Highlighted in each specific medication error case study is how it happened, and what you should take away from these stories to avoid making similar mistakes in the future.

Case Study #1: Incorrectly Calculating Drug Dosages

The Medication Error

nurse on the pediatric floor performed dosage calculations in her head and accidentally administered a dose to an infant patient that was 10 times higher than the prescribed amount.

How It Happened

The nurse was instructed by a doctor to administer 140 milligrams of calcium chloride to her 8-month-old patient. Thinking that there were 10 milligrams in a milliliter instead of 100, she calculated in her head that she'd need to give the patient 14 milliliters of calcium—a dose that was 10 times higher than prescribed.

The Result

By the time the nurse's team discovered the mistake, it was too late. The baby girl died five days later.

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Case Study #2: Right Drug, Wrong Patient

The Medication Error

A nurse at working at a nursing home transcribed a resident's medication order on a different person's chart. Her colleague also failed to properly match the drug with the patient's medication administration record (MAR).

How It Happened

According to the Minnesota Department of Health's official investigative report, two nurses neglected to follow established facility procedures for handling the drug in question. Specifically, the nurse who signed off on the medication put the order on the wrong resident's MAR. The second nurse failed to double-check the order against that wrong patient's chart. Additionally, the entire care team failed to catch the errors for nine days.

The Result

The resident was taking the drug, an anticoagulant (blood thinner), because they had a history of developing blood clots. During the nine-day window, the resident developed clots in their brain that eventually caused a large—and fatal—ischemic stroke.

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Case Study #3: Using the Wrong Administration Route

The Medication Error

To alleviate the symptoms of a patient's allergic reaction, a nurse administered a dose of epinephrine directly into her bloodstream instead of into her thigh.

 

How It Happened

The patient, who also was a physician, went to the ER with signs of anaphylaxis (life threatening allergic response). They rushed her to trauma, where a nurse administered epinephrine to help alleviate her symptoms. Immediately, the patient felt severe, crushing pain flow through her body that caused her to pass out. When she woke up, the patient realized that the nurse had administered the drug via the wrong route. However, it wasn't until after she asked the staff about it that they acknowledged an error had been made.

The Result

The error caused mild but reversible damage to the patient's heart. She continued to suffer from chest pain, palpitations, and exhaustion and she eventually contacted the hospital to launch a formal investigation into the error.

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Case Study #4: Giving Medications at the Wrong Time

The Medication Error

An overnight nurse administered a dose of an antiarrhythmic medication earlier than instructed, which resulted in the patient receiving two doses too close together.

How It Happened

The patient was supposed to take dofetilide every 12 hours. Dofetilide is an anti-arrhythmic drug. By default, the hospital's EHR system set his dosing schedule for 6 a.m. and 6 p.m. The night before his surgery, a nurse saw that the patient was expected to receive meds at 6 a.m., but he was also slated to leave for the operating room before 6 a.m. To keep him from skipping a dose, she administered the medication two hours early, at 4 a.m. It was later discovered that the patient had received his evening dose later than usual, at 10 p.m.—so he ended up taking two doses six hours apart instead of 12 hours apart.

 

The Result

According to the Agency for Healthcare Research and Quality (AHRQ), which published the case study, the patient was found to have "severe QTc prolongation on his electrocardiogram, putting him at high risk for a fatal cardiac arrhythmia." As a result, they had to postpone his surgery until his QTc returned to its regular level.

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Case Study #5: Forgetting a Dosage Due to Fatigue

The Medication Error

nurse was fatigued and forgot to administer the second of two chemotherapy treatments to a patient.

How It Happened

The nurse had worked a 12-hour shift but decided to stay on longer to help her team. Earlier that day, one of her patients had been diagnosed with cancer, so she was now responsible for administering two doses of their chemotherapy treatment. The nurse put one of the doses in a drawer for safekeeping and administered the other to the patient. Once she finished administering the first dosage, she headed home—forgetting about the second dose.

The Result

The nurse's mistake was not discovered until the next day. However, they were able to administer the second dose within the window and the patient was fine.

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