IHP-430 Gabriella Loflin January 14, 2024 1-2 Short Paper The Wrong Medication When opening this case to study, first we need to indicate what happened to the patient. Then finding out why the patient was first admitted. This is important to know so that later when reviewing the medications administered originally are known and approved to be taken compared to what should not have been taken. Once reviewing the medication and why the patient was admitted then we can determine how the wrong medication was administered. Once we know how this situation happened, we can review why it happened and why the policies in place did not stop this from happening. The stakeholders in this case would include the department chairs, the leaders of the hospital, the nursing staff, the physicians, and the patient's families. All of these stakeholders would gather all of the information that they have in regard to this case. This would help ensure that no information had been forgotten or left out. This will also make sure that the same situation does not happen again. To try to understand how a patient was administered medication incorrectly, a root cause analysis would be most beneficial. To start, a "why" did this occur should be asked. Why
did the patient get this medication? Why did the nurse have access to this medication if it was not what the patient needed. Why did the policies put in place does not stop this from happening. Why did this happen to this specific patient, and has it happened to others? All of these are good questions to ask to help break down the process of what lead to this patient receiving the wrong medication. Medication errors can be avoided in the future by having policies put in place to avoid situations like this from happening. Monthly trainings or meetings could also be done. Many hospitals use a system now where medications have to be scanned into a system before being given to the patient, an if it is not time for the medication the system will let the nurse know that that specific medication cannot be administered at that time. These are the things that can be put in place to help ensure that wrongful medication administration is avoided.