FAKULTI KEJURUTERAAN PEMBUATAN

UNIVERSITI TEKNIKAL MALAYSIA MELAKA (UTeM)

OCCUPATIONAL SAFETY AND HEALTH MANAGEMENT

BMFG 4662

ASSIGNMENT PART A

SEM. 1 - SESI 2015/2016

Instructions:
1)This assignment has TWO (2) parts; Part A will be given by Mr Muhammad Syafiq Syed Mohamed and
Part B will be by Mr Ab Rahman Mahmood.
2) For this assignment please work in groups of TWO (2) maximum. In order to prevent any sleeping
members, this is how you divide the work:
Student X : MUHAMAD SHARUL NIZAM BIN ZIN B0512120121
Student Y : Question d

Question a, b, c (total 20 marks)

(total 20 marks)

Please indicate who is X and who is Y.

(a) In this story:

What was the active error committed

Who committed that error

The active error is wrong drug selection that caused by the attending nurse who
charged for taking the drug from narcotic cupboard.
(5 marks)
(b) Describe the classification of that error (slip, lapse or a mistake)?

The wrong drug selection is classify as slip error. Slip error is mean that the action is not what was
intended. Firstly, the doctor wrote an order of 10mg of Morp and explained the RN
about the effect of the drug before instruct the RN to take it at the narcotic
cupboard. The RN was wrongly select the drug which she should take the 10mg of
Morphine instead of 10mg of Hydromorphone. She just take the drug and sign out
one dose of morphine 10mg on the narcotic sign out sheet without realize she take
hydromorphone because the packaging is look alike and she only seen the
hydromorphone in another hospital before this. In easy meaning, she is not really
familiar with that drug.
(5 marks)

(c) Describe all the possible latent causes of error in the story.
The possible lantern cause that can be found in the story are the packaging of the
drug that look alike and both of it located next to each other in the narcotic cupboard
compartment. Although the nurse is a RN that have experienced in handling the patient
and familiar with morphine product since she widely use that drug in her previous
hospital,

she

still

not

with

new

hospital

facilities.

Moreover,

she

never

use

hydromorphone before and only seen it used in an oncology unit before. The patient is
can be called as a disturbance since he try to climb out while the nurse wants to take the
drug from the narcotic cupboard. Other causes is the storage of drug. The position of
morphine and hydromorphone is side by side where close each other in narcotic cabinet.
Since both of the drug is look alike and the nurse is not familiar with the hydromorphone,
it lead the accident happened. Other causes is the RN not alert with the patient side
effect, the RN thought the patients near-immediate complaint of dizziness was too soon
to be morphine-related and thus had a low index of suspicion regarding the potential for
opioid toxicity.
(10 marks)
(20 marks)
=============END OF PART A=================