On 20 February, after fracturing his left forearm, a 74-year-old man was admitted to the Emergency Department. The patient was operated on the same day and the medical procedure went off without any particular difficulty. The day before leaving, the patient was twice given his dose of anticoagulant. The day nurse had forgotten to record the administration of the treatment in the patient's file, so her night colleague also administered the drug, thinking that it had not been done. The following day, when the shifts switched over, the day nurse explained why she had forgotten to write it down, saying that she'd been interrupted by a colleague while administering the treatment. There are three lessons to learn from this event: the importance of keeping a record of administered care in the patient's file; the consequences of interrupting people whilst they are providing care; and the need to ensure a free flow of information at care transition points.
Date de parution : 09/2018
Thème : Medication
Mots clés : medication error, communication, patient record
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