Robert,an experienced nurse,discovered a medication order was incorrectly translated. The pharmacist filled the medication and sent it to be administered to the patient.When the medication arrived Robert questioned the dose and consulted with the nurse manager.The order was clarified with the physician and changed to the correct dose.When reviewing the incident the nurse manager determined the near miss was related to which of the following?

Question

Quizplus · Accepted Answer

The error was initially made by an individual (the person who translated the medication order), but it was allowed to pass through the system (the pharmacist who filled the medication) without adequate checks and balances. It was only caught by another individual (Robert) who noticed the incorrect dose. Therefore, it was a combination of both an individual and system error.

Robert,an Experienced Nurse,discovered a Medication Order Was Incorrectly Translated