Why wrong medication was administered to a patient

Junior (College 3rd year) ・Healthcare&Medicine ・MLA

The 5 WHYs technique is a simple brainstorming method that helps quality improvement teams to identify the root causes of a problem. Once the problem statement has been recognized, the rest of the WHYs allow teams to go beyond the obvious, Yes or No answers. The problem that this paper seeks to understand is one of wrong medication.
The 5 WHYs include:
1. Why wrong medication was administered
a) Poor warning labelling on the drugs.
b) Lack of afterhours pharmacy coverage
c) The nurse administered medication that had not been prescribed by the physician
d) Administration route errors – The nurse administered medication using a route that is different from what had been prescribed (Sarkar et al. 50).
e) Technique error – The medication was incorrectly formulated before medication and there the use of inappropriate procedure caused the doctor to administer the wrong medication (Sarkar et al. 56).
2. Why the doctor prescribed the wrong medication
a) Wrong Patient – The doctor may have had wrong information about the patient. This may have been caused by inadequate records and incorrect reporting.
b) Wrong drug formulation
c) Human factors – Wrong medication may be caused by factors such as fatigue or entering of wrong patient information.
3. Why information was missing in the patient’s chart
Information may be missing in a chart due to the following reasons:
a) Recording on the wrong chart – This might lead into confusion between two patients Inability to document drug reactions or alteration in the patient’s condition.
b) Improper transcribing of orders – Transcribing orders improperly is caused by wrong procedure or unsure drug orders (Kalra 27).
4. Why lab test results had not been entered in the chart
a) Illegible or incomplete records – incomplete records may mean that lab test results may not have been recorded.
b) Lack of a reliable workflow management model that clarifies the responsible individuals to do specific duties, within the set timeframe (Kalra 34).
c) Poor retrospective analyses.
d) Failure to follow up after medication may cause such discrepancy.
5. Why technician did not update the patient’s records
a) Human factors such as fatigue and lapse of concentration may cause discrepancies.
b) Lack of a reliable user interface required to track what would be integrated between the records in transit and the records remaining in the hospital.
c) System failure resulting from the use of automated systems for patient identification and record keeping.

Work Cited

Kalra, Jay. Medical Errors and Patient Safety. Berlin: De Gruyter, 2011. Print.
Sarkar, Indra N, Andrew Georgiou, and Paulo M. A. Marques. Medinfo 2015: Ehealth-enabled Health : Proceedings of the 15th World Congress on Health and Biomedical Informatics. , 2015. Internet resource.

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