Clinical Scenario Analysis · Due 25 Oct by 2000 · Points 100 · Submitting an external tool Students will be required to view the clinical scenario provided and apply the safety and quality matrix (SAC...

CLINICAL SCENARIO ANALYSIS
Table of Contents
Introduction    3
Overview    3
Medication Errors    3
Contributing Factors    3
Reporting    4
Incident Reporting    4
Pre-Incident Measures    4
Principles and Concepts    4
Culture    5
Review Plan Post-Incident    5
Assessment    5
Incident Analysis    5
Comprehensive    6
Concise    6
Multi-Incidents    6
Key Points    6
Potential Failure    6
Actual Failure    7
Recommendations    7
Developing Action Plan    7
Prioritising the Plan    8
Implementation    8
Monitoring    8
Conclusion    8
References    10
Appendix: Description of the Incident/Hazard/Event    12
Introduction
This paper is a critical analysis of scenario where the case of medication error has been occurred. Initially this paper will report the incident with all necessary data. Further, it will be created a review plan, in addition to key points of the potential and actual harm, which took place and which could have taken place. Lastly, it will be concluded with best possible safety measure recommendations to avoid such incidents in future.
Overview
Medication mistakes are responsible for 10% to 18% of all reported hospital injuries. Poor handwriting, insufficient paperwork and a nurse shortage can all lead to medication mistakes (Fathi et al. 2017). This is a nursing study on medication mishaps. The study's goal was to characterise nurses’ perspectives of different medication-related difficulties. The average number of recalled-committed medication mistakes per nurse during the course of their nursing career was 2.2. Pharmaceutical mistakes were more common when medication labels/packaging were of poor quality or broken, author further mentioned. However, in this scenario, there was a shortage of nurses and nurse was overburdened with the responsibilities or maybe she was not focused enough. Nurses were frightened of being disciplined if they reported medication mistakes.
Medication Errors
The IOM classifies medication mistakes as one of five categories of medical errors. Medication mistakes are predicted to occur at a rate of 1.9 per patient each day (Fathi et al. 2017). Approximately 5% of all drug mistakes are fatal and over 50% of these errors are avoidable. Poorly worded orders, calculation mistakes, administration problems and a lack of expertise about patients all contribute to medication errors.
According to the authors, medication mistakes are common among nurses, doctors and pharmacists. Workload, communication issues among the health care team, physical and mental problems, whether or not they were prescribing for their own patients and a lack of pharmaceutical understanding are all risk factors. Nurses prepare and give intravenous drugs ordered by doctors in the United Kingdom, as in most other nations.
Contributing Factors
Pharmaceutical mistakes can occur at any point of the medication procedure, including improperly written orders, dispensing problems, calculation errors and administration errors. Factors leading to medication mistakes may be divided into two categories: systems used in ordering and storing medications and information/communication areas connected with drug administration difficulties (Di Simone et al. 2018). Nursing shortages and workload, i.e., nursing staffing levels, have a substantial impact on patient death rates; and general variables that raise drug error rates, such as infusion pump abuse and inability to explain why errors occur.
Reporting
Medication error prevention is connected to proper reporting of these mistakes (Jones & Treiber, 2018). Many studies have found that nurses underreport drug mistakes. According to nurses, incident reports were used to record just around 25% of all prescription mistakes. Only 3.5 percent of nurses thought all drug mistakes were recorded. There are varieties of reasons why pharmaceutical mistakes are not reported or are under-reported. A major reason of non-reporting or under-reporting is disagreement about what constitutes an error. Overmedication is a typical occurrence reported by nurses (Fathi et al. 2017). Nurse managers expressed worried about the reputation of their organisation.
Incident Reporting
1. Name of the patient – Mrs Johns
2. The incident's date and time - 2pm, date is unknown.
3. Incident location – Inpatient ward
4. A succinct account of the occurrence - There were few points to be considered in the event.
i. Nurse was unavailable at the time of check-up
ii. Nurse was distracted and unfocused.
iii. She gave wrong medicine to the patient.
5. Any witnesses' names – Mrs Stevens, patient next to Mrs Jones
6. Harm done - Due to immense distraction the nurse gave the patient wrong medicine. The medicine contains penicillin, from which the patient is allergic. The patient suffered with minor harm, which could be catastrophic. However, she is recovered.
Pre-Incident Measures
Principles and Concepts
The effectiveness of event analysis in restoring confidence and implementing changes to make care safer is strongly reliant on a collaborative effort. All healthcare practitioners must have a clear understanding of how their organisation will handle occurrences and incident analysis. It's also critical that the organisation follows through on its promises to use analysis techniques equitably and in the way they said they would. The most successful incident analysis takes place in a private setting where participants may safely report and share their thoughts regarding underlying contributing variables without fear of retaliation (Holland, 2019). Regardless of whether the...