The dose was ten times larger than had been prescribed and the baby died. A registrar had prescribed 5ml of sodium chloride but the baby was wrongly given 50ml.
This case is a timely reminder of how mistakes can occur with sometimes devastating consequences.
Clear policies and procedures govern the administration of drugs yet nurses - like other health professionals who prescribe and administer medicines - sometimes do make errors, and near misses. These occur for lots of reasons; nurses are rushing, they get distracted, don’t check name bands, they fail to sign prescriptions or look up a drug in the BNF if they haven’t given it before. Ultimately they occur because health professionals are human beings, and human beings make mistakes from time to time. However, while mistakes will never be completely eradicated, practitioners must do what they can to minimize the risk.
The most frequently cited reason for giving the wrong dose of a drug is calculation error.
Nurses must be numerate to administer drugs safely. They have to be able to calculate doses and with increasingly complex drug regimens they need to be confident that their calculations are accurate.
Anyone administering medicines needs to be regularly reminded of what constitutes safe and effective practice but this is easy to say, less easy to make a reality when staffing is at a premium and opportunities for study leave is limited.
Nursing Times Learning has recognised these challenges and has launched an online unit on Drug Calculations in Practice. After studying it you will be able to:
- Explain different units of measurements used for medicine dosages
- Calculate dosages for medicines in tablet and capsule form
- Calculate dosages for medicines for the weight of a patient
- Calculate dosages for medicines in suspension or solution.
- Calculate the administration rate for continuous IV infusions of medicines and fluids
- Recognise incorrect dosages of medicines and know how to ensure patient safety
On 26 October at 4pm we are hosting a FREE clinical chat with the author of the learning unit, Kerri Wright, senior lecturer at University of Greenwich and author of Drug Calculations for Nurses, published by Palgrave. She will be joined by Philip Marini, retired headmaster and Ofsted registered inspector who worked for Brighton and Sussex University Hospital Trust and Western Sussex Hospitals NHS Trust, providing drug administration numeracy materials for newly appointed nurses and healthcare assistants.
If you aren’t able to take part in the webchat you can email questions to firstname.lastname@example.org or tweet them to @eileenshepherd then read the transcript later, but we hope as many of you as possible will join in to discuss this important issue.
Participating in NT Clinical Chats can contribute to you CPD. How to get the most out of Clinical Chats:
- Look at the topic in advance of the chat and plan questions you would like to ask
- Participate in the chat by posting questions or comments
- Download the transcript after the chat as evidence of your participation. This will be available here after the webchat.
Write a reflection on what you have learned and how you could use this information in clinical practice, to store in your portfolio.