Pediatric Knowledge Discussion

Pediatric Knowledge Discussion

Focused Case Study: Error/ Near Miss Event From last week’s video assignments, select the topic for this week’s assigned paper. Your options are: Dennis Quaid’s Twins, Josie King, or Lewis Blackman’s story. There are several other videos, articles, and even a book (Josie’s Story by Sorrell King (2009) that you may use as further references to assist you in making your decision. **FYI! Although both of these cases involve pediatric patients, you do not need in-depth pediatric knowledge to note the problems that occurred. I hope both of these stories cause you to stop and think for some time prior to making your decision. Both stories are very powerful!! **Look at the processes that occurred during the care of the patient(s) that are indicated in the case and in the dialogue with parents. Josie’s mom continues to travel the world speaking to groups of medical providers. Lewis’ mom also continues to share his story. Assignment  Develop a two page (content) paper that: o Identifies one problem in the care of this patient o Identify a plan of how the outcome could have been improved. o Discuss the presence of any ethical or unethical decision making in the case. o What ethical nursing theory could apply in this case (See Butts & Rich Chapter 9)? o Use references to support your points (minimum of four references) Grading Rubric  Identification of a problem 2 points  Discussion of a specific plan to improve the outcome 6 points  Discussion of ethical or unethical decision making 4 points  Discussion of the nursing theory that could apply 4 points  Spelling, grammar, APA throughout the paper 4 points o (no errors = 4 points, 1-2 errors = 3 points, 3-4 errors = 2 points 5-6 errors = 1 point, greater than 6 errors = 0 points) *include a title and reference page. Please note that APA is worth a total of four points. Please make every effort to have zero APA errors to ensure your receiving all four points. **You will not be penalized for writing more than 2 pages. ***There are many different issues in this case so not everyone will have the same answer, plan or interpretation of the selected case study. You may set up the case study as follows: Problem, Plan, Decision-Making and Nursing Theory Pediatric Knowledge Discussion


Medical errors are an issue of public health significance and a major cause of death in the US. It is a huge problem since it is not easy to identify a regular cause of errors. Even in instances where it is found, providing a viable and consistent solution that minimizes a recurrence is challenging.  According to Gorgich et al. (2016), knowing how a medical error occurs, identifying learning points, and working towards prevention is the best way to address medical errors and improve patient safety. An integral part of the solution is maintaining a culture that helps to recognize challenges in patient safety before implementing viable solutions as compared to maintaining a culture of shame, blame, and disciplinary action. Wakefield (2000) emphasizes the need for healthcare organizations to develop a patient safety culture that focuses on improving healthcare delivery by acknowledging medical errors as challenges that healthcare systems should overcome.

Problem Identification

Dennis Quaid’s, the story highlights how twins received 1000 times the dosage of heparin than what they were supposed to receive.  The incident happened after two pharmacy technicians in a pediatric unit mistakenly delivered 100 vials of heparin. Besides, rather than containing 10 units per milliliter of heparin as required, the vials had a concentration of 10,000 units per milliliter. The mix-up was also due to a similarity of the labels of heparin 10 units and 10,000 units. Although the heparin overdose had significant economic and health implications for the healthcare organization and patients respectively, the twins were fortunate to survive the medication error incident.  The problem is Dennis Quaid’s case occurred at two major points:

Transcribing/dispensing: the incidence was initially an error in a pharmacy dispensation Pediatric Knowledge Discussion

Monitoring/prescribing:  the nurses as well as physicians overlooked the administration and continuous monitoring of heparin. Besides, the dose of heparin that the twins received exceeded the required dose by 1000 times.

Plan to Improve Outcome

The best improvement plan to improve outcomes in the case of Dennis Quaid is developing a medication policy at an organizational level. The policy should highlight and include the following components;

  • Documentation and ensuring the five medication administration rights-nurses should ensure that the right medication is prescribed for the right patent, in the right dosage using the right route, and at the appropriate time. As suggested by da Silva & Krishnamurthy (2016), this can be actualized using a Medication Administration Record (MAR).
  • Adhering to Procedures for Medication Reconciliation-having mechanisms for medication reconciliation when transferring a patient from a unit or institution to another The procedure should include reviewing and verifying every drug against the five rights, how to transfer or discharge patients to another unit, patient and family inclusion to prevent errors (Gorgich et al., 2016).
  • Triple-checking or double-checking procedures- having measures in place of another nurse in a similar shift or incoming shift review orders to ensure accuracy and correct transcription in the record of treatment administration.
  • Using name alerts to prevent mix up

Ensuring appropriate documentation by all staff through proper medication labels, timely recording and legible documentation of administered drugs.\

Ethical Decision Making and Nursing Theory

Nurses have an ethical role to treat all patients with dignity and safeguard them from possible harm. The Theory of Planned Behavior (TPB) is a good theory that healthcare providers can use to promote quality care in clinical settings using predictive factors such as perceived control of behavior, attitude and subjective norms (Steinmetz et al. 2016). Using the TPB, nurse leaders can implement behavior change interventions that impact positively on nurses’ attitude and intention to acknowledge, report and address a medication error. TPB also enhances a nurses’ ability to observed education on patient safety, which increases an individual’s sense of responsibility and self-confidence, making them be more inclined to drug therapy.Pediatric Knowledge Discussion


Gorgich, E. A., Barfroshan, S., Ghoreishi, G., & Yaghoobi, M. (2016). Investigating the Causes of Medication Errors and Strategies to Prevention of Them from Nurses and Nursing Student Viewpoint. Global journal of health science8(8), 54448.

da Silva, B. A., & Krishnamurthy, M. (2016). The alarming reality of medication error: a patient case and review of Pennsylvania and National data. Journal of community hospital internal medicine perspectives6(4), 31758.

Steinmetz, H., Knappstein, M., Ajzen, I., Schmidt, P., & Kabst, R. (2016). How effective are behavior change interventions based on the theory of planned behavior? Zeitschrift für Psychologie.

Wakefield, M. (2000). To err is human: An Institute of Medicine report. Professional Psychology: Research and Practice31(3), 243.



Pediatric Knowledge Discussion