Mary, an RN, is busy with four patients. She receives a new order for an intravenous piggyback (IVPB) medication from the healthcare provider, and orders it from the pharmacy for her patient. When the unit clerk tells Mary that her patient’s IVPB medication has arrived from the pharmacy, Mary quickly picks up the medication bag and begins the infusion. A few minutes later, the patient becomes short of breath. As Mary assesses the patient, she notes to her horror that she mistakenly hung another patient’s IVPB medication for this patient.

1.

Is this an error of omission or commission? Explain.

2.

Is a problem like this the fault of the provider, the hospital, the nurse, the pharmacy department, or the patient care unit, or all of them?

3.

Was this medication error and patient harm a foreseeable breach in the duty of care?