Medicines Administration Case Study

Sapphire is a thirteen year old girl admitted to the general paediatric ward with a lower respiratory tract infection.  She has been prescribed co-amoxiclav (amoxicillin with clavulanic acid) intravenously.  An incident report is filed on the ward because for her lunchtime dose she was accidentally given intravenous amoxicillin.  On questioning the staff involved, the patient identification and calculations had all been carried out appropriately but the wrong vial had been selected from the drug cupboard and thus the wrong drug administered.


This incident is taken seriously by the hospital medicines safety board who discover that it has occurred more than once.  After discussion with the pharmacy team and a focus group of nurses on the ward, a new colour coding system is introduced to help differentiate between these two medications. Staff feedback shows that they feel more confident in administering these medicines correctly.  As the same time the hospital is putting together a business case for electronic drug dispensing systems.