Pediatric Dosing Case Study

Improved Essays
Layla Micheli
Monica Malt
LVN 121
11/17/2017

What were the Contributing Factors to the problems in this Case?
Describe them by category below. Equipment (design, availability and maintenance)
The Pyxis machine is designed to calculate patient medications and doses accurately and should have alerted the nurse when the dosage was too high for a pediatric patient. The Pyxis did not have its own set of protocols pediatric dosing visible for medical staff. Usually maintenance is scheduled on all hospital equipment. The nurse’s skills were not used, by assuming a familiar dose may work.
She did not go find the Drug book or use her electronic technology to find the information she needed to know for the correct pediatric dosing.
There
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Judy the experienced nurse was new to this unit. Being a pediatric nurse, she should of known the accurate dose range for this patient especially for how high the dosage was. Nurse Judy was a Pediatric nurse but also, had very little experience with children. Teamwork (verbal and written communication, supervision and assistance) The order for the that went to the pharmacist should have stood out as a Pediatric order. Due to the fact that is was a STAT order on a medication the Nurse or physician should of called the
Pharmacy to confirm the order was received and that the medication was in stock. The nurse that did a second check on the medication should of found the book or reference ranges herself. If she was familiar to the facility then she would of known where the policy and procedures were and all the pediatric dosage ranges. She failed to help her coworker.
.
Staff (knowledge and skills/training, competence, physical and mental health)
When the new staff began at the hospital they should have been shown where everything was especially pediatric information and references. The staff worked many hours on night shift.
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A second nurse would double check the medication dosing for accuracy and not just give advice. Teamwork The nurse would have knowledge of where pediatric dosing protocols are, The Dr. would need to also know where these protocols are and consult with the Nurse and pharmacists. The pharmacist would have also had a verbal call for a STAT medication. The nurse second check would have been done and if she wasn’t sure she too could have looked in the drug book, online medical recourses just for nurses and physicians and sat down and did the math. Staff:
The staff should communicate clearly to the new staff coming on. The new staff beginning the shift should have a full patient report and read over it before the NOC shift leaves the facility.
All the staff would know where all the policy’s and procedures were located.

Institutional context:
Analyze the root cause of the error made, then develop a plan of action to correct the errors from happening again. Pharmacist are available at all time for provider to consult with about pediatric medications and pediatric dosages.

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