Multifactorial Medication Mishap Case Study Analysis
By Editorial Team Last updated: Jun 21, 2022
Review the Multifactorial Medication Mishap case study and the commentary that follows.
Multifactorial Medication Mishap
Annie Yang, PharmD, BCPS | February 1, 2014
Case Objectives
- Understand the system-based causes of medication errors.
- Describe a model for a systems approach to error analysis.
- Identify weaknesses or failures in key elements of the medication use system.
- Select effective risk reduction strategies to prevent medication errors.
The Case
A previously healthy 50-year-old man was hospitalized while recovering from an uncomplicated spine surgery. Although he remained in moderate pain, clinicians planned to transition him from intravenous to oral opioids prior to discharge. The patient experienced nausea with pills but told the bedside nurse he had taken liquid opioids in the past without difficulty.
The nurse informed the physician that the patient was having significant pain, and liquid opioids had been effective in the past. When the physician searched for liquid oxycodone in the computerized prescriber order entry (CPOE) system, multiple options appeared on the list—two formulations for tablets and two for liquid (the standard 5 mg per 5 mL concentration and a more concentrated 20 mg per mL formulation). At this hospital, the CPOE system listed each choice twice, one entry with the generic name and one entry with a brand name. In all, the physician saw eight different choices for oxycodone products. The physician chose the concentrated oxycodone liquid product, and ordered a 5-mg dose ...
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Instructions
- Explain why a root cause analysis was appropriate for this situation.
- Analyze the impact of using tools such as RCA, FMEA, and PDSA on the quality and safety of patient care.
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