Interprofessional Medication Error Management and Disclosure

Case Description

Carmel Johnson is a 22-year-old female who was admitted for overnight observation after a minor surgical procedure. Learner(s) will receive a handoff from the outgoing nurse who reports that the patient is feeling unwell. Learner(s) will enter the room to assess the patient, identify that she has hypoglycemia from an inadvertent insulin dosing error, contact the nurse practitioner, and administer D50 per the hypoglycemia protocol which will lead to improvement. The patient’s mother, Mary, will be upset and frustrated at the situation. The Nurse Practitioner arrives and gives an apology. Learner(s) will also participate in the apology and discuss the error with the hospital admin.

This scenario can be run with a nurse learner and, optionally, a health-care administration and policy learner or a nursing leadership partner.

Learning Objectives

1. Identify symptoms of hypoglycemia and demonstrate appropriate initial medical responses to stabilize the patient.
2. Recognize and correct medication errors, specifically in the administration of insulin, and manage the acute effects of such errors on patient health.
3. Practice how to communicate effectively and transparently with colleagues and patients when disclosing medical errors, focusing on clarity and precision in conveying what happened.
4. Demonstrate empathy and emotional intelligence by acknowledging the patient’s distress, responding with sensitivity and understanding during the error disclosure process.
5. Take responsibility for errors, regardless of the circumstances, and articulate an apology, highlighting the importance of accountability in healthcare.
6. Identify potential systemic issues that lead to medical errors and propose practical improvements or preventative measures to avoid future occurrences, thereby enhancing patient safety.