HTHSCI 2H03 Lecture Notes - Lecture 5: Intensive Care Unit, Swiss Cheese Model, Medical Error

• School: McMaster University
• Department: Health Sciences
• Course: HTHSCI 2H03
• Professor: kirsten

Document Summary

Learning objectives: explain the impact of medication errors on patient outcomes and the health care system, define common terminology, describe the medication use process and where and what types of errors can occur in this process. Identify factors which may contribute to medication errors: discuss strategies to prevent medication errors. A patient who was receiving a methadone maintenance dose of 85 mg daily by mouth was admitted to hospital after giving birth to her child at home. Just hours after the birth, the patient received her first hospital dose of (cid:373)ethado(cid:374)e. oo(cid:374) afte(cid:396), the patie(cid:374)t"s hus(cid:271)a(cid:374)d (cid:374)oted that she (cid:449)as (cid:271)e(cid:272)o(cid:373)i(cid:374)g increasingly delirious and agitated. As the patient became progressively sedated, the hospital staff intervened with the administration of intravenous (iv) naloxone. Despite several doses of naloxone, the patie(cid:374)t"s (cid:396)espi(cid:396)ato(cid:396)(cid:455) (cid:396)ate (cid:272)o(cid:374)ti(cid:374)ued to d(cid:396)op. This (cid:396)esulted i(cid:374) ad(cid:373)issio(cid:374) to the i(cid:374)te(cid:374)si(cid:448)e (cid:272)a(cid:396)e u(cid:374)it (cid:894)icu(cid:895), initiation of an iv naloxone infusion, multiple other interventions, and an extended hospital stay.