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How did the nurses and senior resident prevent the administration of the incorrect magnesium sulfate dose?

The nurses and senior resident prevented the administration of the incorrect magnesium sulfate dose through verbal communication and cross-checking. The nurse repeated the dose aloud to another nurse, who verified it against a printed chart and identified the error. Additionally, the senior resident stopped the administration when the error was communicated aloud.

The prevention of the incorrect magnesium sulfate dose was achieved through effective communication and verification processes. Initially, the nurse prepared the medication based on memory due to a faded chart, which led to an error. However, before administering the medication, the nurse followed protocol by verbally repeating the dose strength to another nurse. This second nurse cross-checked the information against a printed chart, catching the error in time. Furthermore, the senior resident also identified the error when the dose was communicated aloud, preventing the incorrect administration. This process highlights the importance of verbal feedback and cross-checking in clinical settings to ensure patient safety.

Key points

  • Nurse prepared medication based on memory due to faded chart.
  • Verbal repetition of dose strength by the nurse to another nurse.
  • Cross-checking against a printed chart identified the error.
  • Senior resident stopped administration upon hearing the error.
  • Effective communication and verification prevented incorrect dose.
Source:The Nexus between Nursing and Patient Safety· Technology and Patient Safety: A Cause and Solution to Complexity· p. 229–247

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Cover of The Nexus between Nursing and Patient Safety

The Nexus between Nursing and Patient Safety

Cynthia A. Oster, Jane S. Braaten

Springer Nature Switzerland AG

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