Legal Incident Reporting Requirements: Vasopressin Overdose

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Recommended: Samples of medical error

In the case study identify the incident and explain the problem that might trigger a root cause analysis. In this case study, a patient admitted to the intensive care unit (ICU) with septic shock requiring vasopressors that suffered an MI in the course of his treatment due to vasopressin overdose as the incident. The problem that triggered a root cause analysis was likely related to a log increase in the dose of vasopressin because of a prescribing error, pharmacy issues also figured prominently in this error, the computerized physician order entry (CPOE) system that did not eliminate medication errors and domino effect to the nurse that started the medication that eventually caused the patient to have an MI. The patient in this case was receiving the medication vasopressin, at a dose of 0.4 units/min, a dosage used for gastrointestinal hemorrhage and variceal bleeding rather than the correct dose of 0.04 units/min for treating shock. The vasopressin order was incorrectly written by a resident physician after he received a verbal order from his supervising critical care fellow (Flanders, S. & Saint, S., 2005). The dose that was used for the patient was so high that it acted as a vasoconstrictive agent to reduce the blood flow and facilitate hemostatic plug formation in the bleeding vessel thus causing the MI (complication of high dose vasopresson infusion) (Cagir, B. & Katz, J.). Furthermore, the nurse caring for this patient administered the incorrect dose of vasopressin as a result of the domino effect. In fact, the incorrect dose was given for more than 16 hours, which means that more than one nurse was involved in the error. It was not until a nurse was discussing the medication dosing with nursing students that the incorrect ...

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... Root Cause Analysis in Response to a Sentinel Event. Retrieved on March 2014 from world wide web at http://www.pedsanesthesia.org/meetings/2004winter/pdfs/heitmiller_Sentinel.pdf
Orlando Regional Healthcare, Education & Development. (2004). Patient Safety: Preventing Medical Errors. Retrieved on March 2014 from world wide web at http://www.orlandohealth.com/pdf%20folder/patient%20safety.pdf
Scott,D.M,A. (2011, May 31). How to Complete an Incident Report. Retrieved on March 2014 from you tube at https://www.youtube.com/watch?v=-MRJUC6HgzQ
WebMD. (2005-2014). Heart Disease Health Center. Retrieved on March 2014 from world wide web at http://www.webmd.com/heart-disease/guide/heart-disease-heart-attacks
Wolf, Zane Robinson & Hughes, Ronda G (n.d.). Error Reporting and Disclosure. Retrieved on March 2014 from world wide web at http://www.ncbi.nlm.nih.gov/books/NBK2652

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