Building a Safe Medication Management System

Case Study : Mike is a nurse working in the newborn intensive care unit (NICU) in a large tertiary care medical center. He has gone to the medication room to pick up a medication ordered for one of his newborn patients. While in the medication room, he scans the bar code on the medication to ensure this is the correct drug for his patient and also confirms that this medication matches the ordered drug. He returns to the NICU and scans the bar code on the medication again, as well as the bar code on the patient's ID band, confirming a match. The drug Mike needs to administer to this patient is considered a high-risk medication. Per hospital policy, Mike must have another nurse confirm the medication before administering it to his patient. As Mike is preparing to ask another nurse to confirm this high-risk medication, the respiratory therapist stops by to ask Mike a question about his patient. During this conversation, a code blue alert is called; Mike and the respiratory therapist complete their conversation and Mike administers the medication to his newborn patient.

  1. What negative outcomes could this patient experience because of this situation?
  2. What step in the medication administration process was missed?
  3. How could Mike have used the skill of mindfulness to increase his awareness of distraction?
  4. How could a distraction-free policy and subsequent culture have altered the circumstances presented in this case?