An ambulance was dispatched to attend to a 55 year-old patient with heart failure in the community. While treating this patient, a paramedic mistakenly pushes 4 milligrams of intravenous norepinephrine instead of the intended lookalike vial of 1 milligram of bumetanide (bumex).
the patient immediately develops a supraventricular tachycardia, becomes hypertensive, and deteriorates into ventrivular fibriliation. Resuscitative efforts are unsuccessul, the patient is pronounced dead on arrival at the ED

Using the information presented: answer the 3 following questions
1. identify and outline, from a quality perspective, the errors made by the paramedic in this clinical scenario
2. analyse the contributing humna and system error factors and apply your findings to this case
3. describe the process and systems actions you would recommends to improve patient safety and prevent a similar error by another paramedic
critically analyse the case -try to use your ability of understanding the principles of human factors and system factors in error causation, the models and concepts or error identification, and preventive strategies/recommendations you would use to reduce errors and improve patient safety

 

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