Pharmacology

MEDICATION ERROR CASE STUDY

The incident took place at General Hospital, a 500-bed tertiary care facility, where the patient,

Mr. Smith, a 65-year-old male, was admitted for elective surgery to address a chronic orthopedic

issue. Mr. Smith has a history of hypertension and diabetes, managed with a combination of

antihypertensive and antidiabetic medications.

Mr. Smith was admitted to the hospital, and the nurse documented the patient's home

medications, including lisinopril (an ACE inhibitor) for hypertension and metformin for diabetes

in the electronic health record system (EMR).

Mr. Smith underwent preoperative assessments, and the provider prescribed various medications

to be administered preoperatively, including a prophylactic antibiotic, Amoxicillin 2 grams IV,

once and the pain management drug, Oxycodone 5 mg PO q4h, for pain. These medications were

entered into the hospital's EMR. However, the provider did not complete the medication

reconciliation process; thus, the lisinopril 10 mg PO per day and metformin 500 mg PO per day

home medications were not included in the active list of medications. The pharmacy, unaware of

the missing medications, dispensed the prescribed antibiotic and pain management drug.

The nursing staff received medication orders for prophylactic antibiotics and pain management.

However, the omission of lisinopril and metformin from the orders went unnoticed. The nurse

administered the scheduled medications without cross-referencing with the patient's pre-

admission medications.

Postoperatively, Mr. Smith's blood pressure began to rise, and his blood glucose levels were

elevated. The nursing staff, recognizing the issue, investigated the patient's medication history

and discovered the oversight. The provider was contacted and ordered lisinopril 10 mg PO per

day and metformin 500 mg PO per day in the EMR. The missing antihypertensive and

antidiabetic medications were promptly administered to Mr. Smith.

On the morning of the second postoperative day, the nurse responsible for Mr. Smith’s care

mistakenly administered Oxycodone 10 mg instead of the prescribed 5 mg. Within an hour of

receiving the higher dose of Oxycodone, Mr. Smith experienced a significant drop in blood

pressure, leading to dizziness and lightheadedness. The nursing staff promptly identified the

error when they noticed the unexpected change in vital signs during routine monitoring.