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Novice Nurse Administers Excessive Medication Dosage
ISSUE: What is required to ensure proper communication of a medication dose by a telephone order?
A 58-year-old patient in the intensive care unit of a medical center was recovering from cardiac bypass surgery. His recovery progressed normally until he began to develop a cardiac arrhythmia two days after the surgery. The nurse overseeing his care, a very recent graduate, informed a supervising nurse that the patient was experiencing an arrhythmia. The supervisor, also a relatively recent graduate, instructed her to telephone the patient's cardiologist. The cardiologist intended that the patient receive 0.25 milligrams of digoxin. The nurse did not repeat his order to him or confirm the dosage he had prescribed, and the physician did not request that she repeat it. She mistakenly informed her supervisor that the physician had prescribed 1.25 milligrams of digoxin, and the supervisor telephoned the order to the pharmacy.
The supervisor, believing that the patient's condition was worsening, told the nurse not to wait for the pharmacy to deliver the medication, but instead to obtain the digoxin from the stock of medicine in the intensive care unit and to administer it. The nurse obtained three ampules of digoxin and administered two and a half of the ampules into the intravenous line. Shortly after she had administered the digoxin, the pharmacy called the supervisor, questioning the amount of digoxin she had ordered. It was then that both realized that they had administered five times the amount of digoxin actually prescribed. Despite emergency treatment including Digoxin Immune Fab, the patient developed multiple complications and ultimately underwent surgeries to remove a portion of his colon and to amputate his right leg.
The nurse, although assigned to care for various patients in the intensive care unit, had never administered digoxin before she administered it to this patient. Before her call to the cardiologist, she had reported by telephone the condition of a patient to the attending physician no more than five times. She found such calls difficult. The supervising nurse had never worked with the nurse before that evening. Additionally, the charge nurse had assigned the nurse and the supervisor separate patients. The supervisor believed that her responsibility in supervising the nurse was merely to answer any questions she might have had.
A 58-year-old patient in the intensive care unit of a medical center was recovering from cardiac bypass surgery. His recovery progressed normally until he began to develop a cardiac arrhythmia two days after the surgery. The nurse overseeing his care, a very recent graduate, informed a supervising nurse that the patient was experiencing an arrhythmia. The supervisor, also a relatively recent graduate, instructed her to telephone the patient's cardiologist. The cardiologist intended that the patient receive 0.25 milligrams of digoxin. The nurse did not repeat his order to him or confirm the dosage he had prescribed, and the physician did not request that she repeat it. She mistakenly informed her supervisor that the physician had prescribed 1.25 milligrams of digoxin, and the supervisor telephoned the order to the pharmacy.
The supervisor, believing that the patient's condition was worsening, told the nurse not to wait for the pharmacy to deliver the medication, but instead to obtain the digoxin from the stock of medicine in the intensive care unit and to administer it. The nurse obtained three ampules of digoxin and administered two and a half of the ampules into the intravenous line. Shortly after she had administered the digoxin, the pharmacy called the supervisor, questioning the amount of digoxin she had ordered. It was then that both realized that they had administered five times the amount of digoxin actually prescribed. Despite emergency treatment including Digoxin Immune Fab, the patient developed multiple complications and ultimately underwent surgeries to remove a portion of his colon and to amputate his right leg.
The nurse, although assigned to care for various patients in the intensive care unit, had never administered digoxin before she administered it to this patient. Before her call to the cardiologist, she had reported by telephone the condition of a patient to the attending physician no more than five times. She found such calls difficult. The supervising nurse had never worked with the nurse before that evening. Additionally, the charge nurse had assigned the nurse and the supervisor separate patients. The supervisor believed that her responsibility in supervising the nurse was merely to answer any questions she might have had.
From your analysis of the case, assess whether the following statesments are true or false:
| * | A physician has a duty to ensure that verbal/telephone orders are correctly understood both as to medication and dosage. | True or False |
| * | A nurse has no duty to question a physician's apparently excessive medication order because the physician is ultimately responsible for the patient's care. | True or False |
| * | A supervisor of a recent graduate may safely assume that the supervisee will know when to seek advice. | True or False |
Expand to check answers
GENERAL PRINCIPLE: When telephone orders are necessary, repeating back the names of the medication and the dosage is required to ensure proper medication administration.
APPLIED PRINCIPLE: The patient was under the care of a recent nursing graduate, and close scrutiny was required by the supervisor. The nurse should have verified that she correctly heard and recorded both the medication and the dosage. Repeating back both would have confirmed the order to the nurse and the cardiologist. The cardiologist also should have taken reasonable steps to ensure that the proper dosage was communicated and understood.
Three ampules to obtain sufficient medication should have been a red flag to the nurse that there was a strong possibility that the dosage was in error and needed to be confirmed with the cardiologist.
The charge nurse and the hospital had a duty to properly instruct the nurse and the supervisor as to what constituted adequate supervision. Assigning a recent graduate independent responsibility for a critically ill patient without direct supervision was a formula for injury.
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APPLIED PRINCIPLE: The patient was under the care of a recent nursing graduate, and close scrutiny was required by the supervisor. The nurse should have verified that she correctly heard and recorded both the medication and the dosage. Repeating back both would have confirmed the order to the nurse and the cardiologist. The cardiologist also should have taken reasonable steps to ensure that the proper dosage was communicated and understood.
Three ampules to obtain sufficient medication should have been a red flag to the nurse that there was a strong possibility that the dosage was in error and needed to be confirmed with the cardiologist.
The charge nurse and the hospital had a duty to properly instruct the nurse and the supervisor as to what constituted adequate supervision. Assigning a recent graduate independent responsibility for a critically ill patient without direct supervision was a formula for injury.
| * | A physician has a duty to ensure that verbal/telephone orders are correctly understood both as to medication and dosage. | True |
| * | A nurse has no duty to question a physician’s apparently excessive medication order because the physician is ultimately responsible for the patient’s care. | False |
| * | A supervisor of a recent graduate may safely assume that the supervisee will know when to seek advice. | False |