A medication error refers to any preventable event that may lead to inappropriate medication use
or patient harm. These errors can occur at any stage of the medication use process, from
prescription and dispensing to administration and monitoring. Medication errors encompass a
wide range of mistakes, including incorrect dosage, drug interactions, administration route
errors, and prescription of the wrong medication.
This assignment is to enhance your understanding of the critical role that informatics plays in
healthcare, specifically in the context of medication management. Through the examination of a
medication error, you will develop a deeper appreciation for the impact of information systems
on patient safety, quality of care, and overall healthcare outcomes.
analyze a medication error case study using pharmacology and informatics materials to analyze, identify, and propose solutions to decrease the risk of medication errors. The case you will review can be found within the Medication Error Case Study document as found as a resource within the assignment in Canvas.
For this paper, after identifying and describing the medication errors in the case study, you will research and identify the factors contributing to the medication errors. Based on these findings, you will identify improvements to be made and explain how the use of informatics technology can eliminate or decrease the risk of the medication errors.
You will write a paper at least 1,250 words in length in current APA format on your analysis.
The title page and the references do not count towards the 1,250-word count requirement. Be sure to include all of the following within your paper:
• Identify and describe at least 2 the medication errors from the Case Study.
• Identify and describe at least 3 factors that contributed to the medication errors.
• Based on the findings, identify improvements to be made and explain how the use of
informatics technologies (minimum of 2) could have eliminated or decreased the risk of
the medication errors.
Wrong Drug Dispensation and Administration (The Error of Commission)
The first medication error is the dispensing and subsequent administration of the Wrong Drug. The patient was ordered Metoprolol, a beta-blocker, but received Methotrexate, an antimetabolite chemotherapy drug. This error is a classic example of a 'look-alike/sound-alike' (LASA) confusion compounded by poor system checks.
Pharmacologically, Metoprolol's action is to block beta-1 adrenergic receptors, reducing heart rate and blood pressure, with a low risk profile for an elderly patient at this dose. Conversely, Methotrexate is a high-alert medication that inhibits folic acid metabolism, thus interfering with DNA synthesis, which is particularly toxic to rapidly dividing cells like those in the bone marrow and gastrointestinal mucosa. Receiving this drug when it was not indicated resulted in severe patient harm—a true Adverse Drug Event (ADE)—demonstrated by the symptoms of mucositis and myelosuppression (as documented in the case study's outcomes). The administration route (oral) and frequency (daily for five days) further compounded the toxicity, as Methotrexate for non-oncologic indications is typically dosed weekly.
2. Incorrect Dosage/Frequency (The Error of Prescribing and Administration)
The second medication error is a severe Incorrect Dosage/Frequency error. The intended drug, Metoprolol, had a twice-daily frequency. The administered drug, Methotrexate, was dosed daily for five consecutive days. This frequency of daily administration for Methotrexate is profoundly toxic outside of specific, high-dose oncology protocols, which this patient did not require.
Pharmacologically, the patient received a cumulative dose over five days that quickly exceeded safe, therapeutic levels for non-oncological use, leading to the fatal outcome. The administration error was likely a cascade failure beginning with a poorly written or transcribed order and continuing with a lack of clinical knowledge or double-checking by the dispensing pharmacist and administering nurse regarding the standard dosing frequency for Methotrexate (which should typically be weekly for conditions like rheumatoid arthritis, not daily). The nurse administering the drug failed to apply their pharmacology knowledge to question a non-oncology patient receiving a high-alert drug daily, which constitutes a profound lapse in the "Right Dose, Right Frequency" check of the five rights of medication administration.
Sample Answer
Analysis of a Medication Error Case Study: Wrong Drug, Wrong Dose
This paper will analyze a hypothetical yet common medication error case study involving a "Wrong Drug, Wrong Dose" error in a hospital setting, illustrating the critical role of informatics in preventing patient harm.
Identification and Description of Medication Errors
In a representative medication error scenario, an elderly patient, Mr. Smith, with a history of hypertension and a recent fall, is hospitalized. The physician intended to prescribe Metoprolol Tartrate 25 mg orally twice daily for his blood pressure. However, due to several systemic failures, the patient received Methotrexate 2.5 mg orally daily for five days, a high-alert chemotherapy and immunosuppressive drug, leading to significant myelosuppression and severe mucositis.