Mr. Smith, who has diabetes and hypertension is a patient on a medical surgical unit status post hip surgery. The computer systems in the hospital are down. Nurse Jones, who was covering for a colleague, took a verbal phone order to administer Humalog Insulin to Mr. Smith. Because of a poor telephone connection, Nurse Jones heard the order from the prescribing physician as 20 units of Humalog Insulin instead of 10 units of Humalog Insulin. The bar coding system was also not working so Nurse Jones could not check the order in the system. Nurse Jones administered the Humalog Insulin, and Mr. Smith’s blood sugar dropped precipitously and he passed out. The Nurse Manager disciplined Nurse Jones and told her she might be fired.
Using a systems theory, examine the case and propose solutions that would prevent a similar error from happening in the future. Remember that a systems framework moves from a punitive model where individuals are viewed as at fault, to a process model where faults in the system are viewed as resulting in errors.