NU141 Unit 8 Medication Error Analysis Example

Celexa Ordered, Celebrex Given: A Medication Error Analysis of Two Look-Alike Brand Names on a Composite Medical Unit, the Pharmacology of What the Patient Received and Missed, and the System Defenses That Failed in Sequence

[Student Name]

Purdue University Global

NU141: Pharmacology for Nursing

Unit 8 Medication Error Analysis

[Instructor Name]

[Date]

The unit, staff and patient are composite; doses and values are bracketed where illustrative, and the analysis follows a systems approach rather than individual blame.

The Event

[Mrs. H.], a composite 69-year-old woman, was admitted for a urinary tract infection. Her daughter brought a handwritten home medication list that included "Celexa 20 mg daily." During admission, the medication was entered as Celebrex [200] mg daily, selected from a drop-down list after typing the first four letters. The pharmacist verified the order, which was a reasonable dose for celecoxib. Nurses gave it each morning for three days, scanning the barcode, which matched the order. On day three Mrs. H. told a nurse she felt "low and teary, like before I started my pill," and asked when she would get her "mood medicine." The nurse checked the order, compared it with the daughter's list, and recognized the mix-up.

What She Received: Celecoxib

Celecoxib is a nonsteroidal anti-inflammatory drug that selectively inhibits cyclooxygenase-2, reducing prostaglandins involved in pain and inflammation. In an older adult with an active infection and a risk of dehydration, it carries specific risks: prostaglandins help maintain blood flow to the kidneys, so blocking them can reduce kidney function, especially with volume depletion; it can raise blood pressure and cause fluid retention; and it adds to bleeding risk with anticoagulants (Burchum & Rosenthal, 2022). Mrs. H. was also receiving enoxaparin for clot prevention. Over the three days her creatinine crept up by [0.4] mg/dL, to [1.3].

What She Missed: Citalopram

Citalopram is a selective serotonin reuptake inhibitor used for her depression. Stopping it abruptly for three days can bring on withdrawal-type effects, among them lightheadedness, short temper, broken sleep and a dip in mood, and risks a return of depressive symptoms. Her tearfulness fit that picture.

The patient noticed the error before the system did, because she felt the absence of the drug she needed.

How the Error Happened

Using a systems approach, the analysis looks for the conditions that allowed a predictable human slip to reach the patient, rather than for someone to blame (Reason, 2000). Five defenses failed in sequence:

1. Source: a handwritten list using a brand name, open to misreading.

2. Order entry: a drop-down list that showed Celebrex after four typed letters, with no indication or alert.

3. Verification: the pharmacist checked dose and interactions, but the dose was plausible for the wrong drug and no indication was attached.

4. Administration: barcode scanning confirmed that the drug matched the order, not that the order matched the patient's need.

5. Reconciliation: no one compared the admission orders with a second source, such as the pharmacy fill history, within the first day.

Celexa and Celebrex are a known confused pair on the ISMP list, which recommends strategies such as entering an indication with each order and using generic names (Institute for Safe Medication Practices, 2023).

The Nurse's Check at Each Dose

Three nurses gave the drug on three mornings, and each followed the rights of medication administration as most of us are taught them: right patient, drug, dose, route and time, all checked against the order. Every check passed, because each compared the drug with the order rather than with the patient. The right reason, sometimes added as an extra right, would have caught it: asking "what is this for?" and comparing the answer with what the patient has. None of the nurses knew Mrs. H. took an antidepressant at home, because the order screen did not show indications, and she did not recognize the capsule as different until her mood changed. The analysis does not fault the nurses for missing what the system hid from them, but it does show where one question would have helped.

Telling the Patient

Mrs. H. and her daughter were told what happened on the same day, in plain language, by the nurse and the prescriber together: which drug she received, which she missed, what effects that could have had and what was being done. Her daughter asked whether the handwritten list had caused it. The nurse explained that the list was one step among several, and that the hospital was changing how lists are entered so it would not depend on handwriting.

Response

Celecoxib was stopped, citalopram restarted, the prescriber and patient informed, and the event reported through the facility system. Her creatinine returned to [1.0] after fluids, and her mood improved within a week.

Recommendations

Require an indication field for home medications entered on admission, so "depression" next to Celebrex would stand out. Show generic names with brand names in drop-down lists. Complete medication reconciliation with at least two sources within [24] hours. Teach nurses to ask patients what each medicine is for at the first dose; Mrs. H. would have said "my mood pill."

References

Burchum, J. R., & Rosenthal, L. D. (2022). Lehne's pharmacology for nursing care (11th ed.). Elsevier.

Institute for Safe Medication Practices. (2023). ISMP list of confused drug names. Institute for Safe Medication Practices.

Reason, J. (2000). Human error: Models and management. BMJ, 320(7237), 768-770. https://doi.org/10.1136/bmj.320.7237.768