Reference no: EM133890415

Communicate effectively with patients, families, and members of the health care system to address issues and generate solutions.

Case Study

You are a physician making patient rounds and arriving at Mrs. Mangar's room. She's an elderly lady in her late 60s who recently had colon surgery. She is also the wife of a prominent physician at the hospital. She has been known to be somewhat contentious with the nursing staff.

However, today she states she was just given a shot of insulin to cover her elevated blood sugar and the amount of insulin did not seem to be the usual amount. Even though Mrs. Mangar often complains, you are somewhat concerned about this observation and decide that it would be best to check on this. You ask the charge nurse to review the dose of insulin given. She, in turn, finds Mrs. Mangar's nurse, who states that, as ordered, she had given the patient 80 units of insulin. You immediately become pretty alarmed, as this is a substantial dosage. You ensure that the patient is given a large amount of glucose supplement and that her blood sugar is monitored every 15 minutes for the next two hours.

To follow up, you also review the chart and note an order from the house physician to give Mrs. Mangar 8.0 units of insulin. You can readily see how this could quickly appear to be 80 units.

You schedule a meeting with the charge nurse, the nursing supervisor, the Director of Nursing, and the treating nurse to determine what can be done to prevent this error in the future.

Question

Suggest system process improvements that might reduce the likelihood of similar errors.