Health care providers are responsible for ensuring patient safety and quality of care at all times. Nurses play a vital role in provision of patient care. Many of the tasks of nursing carry some degree of risk, with medication administration having one of the greatest risk factors. Serious errors may occur in approximately 2 per 1,000 prescriptions (Lesar et al, 1990). The rate of adverse drug events are estimated at approximately 1%, with 12% to 30% of them classified as serious of life threatening ( Lindquist & Gersema , 1998).
Health care providers enter into a trust relationship with their patients, none more so than nurses. It is the betrayal of trust that is often part of the motivating factor of patients and their families when malpractice claims are brought against health care providers (Kraman & Hamm, 1999).
In Florida a young woman with Guillian-Barre syndrome died from a medication error. The case went to court and a multimillion dollar settlement was reached when it was determined the woman was given succynylcholine which causes a fatal reaction in those with Guillian-Barre (floridahealthcarelaw.com, 2011).
Another case which resulted in a fatality involved a 32-year-old woman who underwent removal of her tonsils and adenoids. Her post op analgesia included a PCA, Phenergan 25mg IV q 4 hours prn for pain, Compazine 10 mg po q 4 hours prn for nausea, Benadryl 50 mg po q 4 hours for itching and Halcion 0.25 mg hs. The PCA was set for 1mg /activation with a 6 minute lockout a bolus of 5mg morphine plus 25 mg Phenergan was given IV. Pt was administered 25 mg Phenergan IV at 1500 and 1900 and 50 mg Benadryl at 1900. The patient reported nausea at 2000 requesting Tums. The nurse reported to the patient that the medication was not ordered, but the physician could be contacted to ask for an order. The nurse also informed the patient that Compazine was ordered for nausea. The patient chose to take Compazine...