Medication error, a word that can have hospital staff quaking in their shoes, skin pallor, and hair prickling; leaving a client to gather the pieces after a miscalculated error. This type of event is termed; sentinel event. According to Taylor’s Fundamentals of Nursing, “The Joint Commission’s Sentinel Event Policy defines a sentinel event as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof (129).” Suddenly, Florence Nightingale’s oath shatters because staff “[…] knowingly administer a harmful drug” containing contaminants, potentially diminishing the patient’s quality of life. How could this happen? Using only one insulin pen between multiple patients.
Sentinel Event Case: Gordon Hayes
There are numerous instances of pharmacological sentinel events involving insulin ordinarily a high alert medication. One instance is accidental or intentional use of an insulin pen amongst multiple patients; situating them at risk for blood-borne pathogens. This type of medication error necessitates prevention before reaching the patient. Gordon Hayes a seventy-three-year-old who lives in Ansonia, …show more content…
Henke’s Med-Math Textbook indicates, “Faulty technique in administering medications, especially injections that result in injury [or illness], is [a] common medication error (378).” Purportedly, the five nurses involved with this client’s care were improperly educated for proficient insulin pen use (Cuda, 2014). Subsequently, Hayes was unwittingly inoculated with the hep C virus. However, other causes leading up to pharmacological errors include: exhausted or overworked staff, an increase of patient to nurse ratios, poor time management, and the many distractions in hospital settings. This may lead to some questionable practices among nurses, for example sharing an insulin pen to save a few