Medical Assistant Prep / Unit 6 MAS 144 review, 2 to 3 minutes
An Answer That Did Not Make Sense
The idea
This case is constructed for this course, with a made-up medicine and a practice order. It shows how the habit of asking whether an answer makes sense stops an error before it reaches a patient.
In practice
In a practice where medical assistants are trained and allowed to prepare certain oral liquids, a medical assistant works a weight-based practice order for a child. The order is for a made-up medicine at five milligrams per kilogram, and the child's chart lists a weight of thirty-three pounds. She sets up the problem quickly and gets an answer of one hundred sixty-five milligrams. It looks too large for a small child, so she stops before preparing anything. Rechecking her setup, she finds that she multiplied by the weight in pounds without converting to kilograms. She redoes the problem with one kilogram over two point two pounds: thirty-three pounds is fifteen kilograms, and fifteen times five gives seventy-five milligrams. Seventy-five fits a child of that size, but she does not rely on her own check alone. She asks a colleague for the second check the practice requires, and she confirms the order with the provider before preparing the medicine. Afterward, she reports the near miss through the practice's incident process, so the team can see how easily a missing conversion slips through.
Where people slip
Her skill in arithmetic was not what protected this child. Three habits did: she asked whether the answer made sense, she used the required second check, and she reported the near miss. A practice that hears about near misses can fix the conditions that cause them; one that hears nothing keeps those conditions in place.
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