Case Study: Medication Errors That Cause Death

An experienced nurse Julie Thao was taking care of 16-yeas old Jasmine Gant who was about t give a birth. Thao is accused of making a mistake that had terrible and tragic result on the life of a pregnant teenage, unborn child, Gant’s family, health care, and Thao’s life. Thao mistakenly gave Gant an epidural anesthetic intravenously instead of an IV antibiotic for a strep infection. Within minutes of receiving the epidural IV, Gant suffered seizures and died. Her child, a boy, was delivered by emergency Caesarean section and survived. So what caused this tragedy to happen? According to investigation, Thao improperly removed the epidural bag from a locked storage system without authorization, she did not scan the bar code, which would have told

Nurses are responsible for multiple patients on any given day making medication errors a potential problem in the nursing field. Medication administration not only encompasses passing medication to the patients yet begins with the physician prescribing the medication, pharmacy filling the correct prescription and ending with the nurse administering and monitoring the patient for any adverse effect from the medication. According to the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP), ‘A medication error refers to any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional,

a) Pharmacists have ethical and legal obligations to ensure that the prescriptions they fill are valid, both in that the physician must be prescribing the medication for a valid reason and that the person filling the prescription must be doing so for valid therapeutic reasons (ASHP, 2008; Brushwood, n.d.). The court needs to take these obligations into account, and then must determine whether the frequency with which the prescription was refilled would have required a pharmacist to check with the patient's physician or at least another pharmacist in order to determine if the pattern represented abuse (Brushwood, n.d.). The basic considerations before the court, then, are the pattern of behavior (i.e. prescription refilling) represented in the facts and the relationship of this pattern to the legal and ethical standards of pharmacists. The addition was certainly a foreseeable consequence, and this means that standard applications of negligence torts might also be applicable.

In this situation by reporting the event, the organization can do something to fix the problem, maybe change the way that their medications are packaged or have two nurses to verify that the correct medication is given. Organizations should focus more on finding solutions instead of looking for people to blame.

Currently, more responsibilities are being given to the pharmacy technician that were traditionally performed by pharmacists, such as clarifying prescriptions and entering orders. With these additional responsibilities for the pharmacy technician, this will allow the pharmacist to spend additional time with patients. However, with these additional responsibilities enables more opportunities for error. In 2008, a study was performed at Wentworth-Douglass Hospital, a 178 bed acute care facility

Errors made while administering medications is one of the most common health care errors reported. It is estimated that 7,000 hospitals deaths yearly are attributed to medication administration errors.

Excellent outline for your quality improvement initiative that addresses medication errors. I like how you describe the closed-loop medication administration process that includes all members of the interprofessional team. Your references are also well researched and current. From the outline, it is unclear what the barriers and implementation strategy are to reduce medication errors. One suggestion I would make is to look at the grading rubric. There are four main points that the rubric requires to complete the objectives for the paper. I usually create headings that align with the rubric, this helps me organize my thoughts and to meet the objectives of the assignment.

like anyone else, are not perfect. They can make mistakes, and while there are many policies and procedures that are used in nursing to help prevent mistakes, they do happen. In 2006 a nurse who had worked 16 hrs slept for a few hours at the hospital, and then worked another 8 hours, was taking care of a mother-to-be during her induction. Between the new computer system that the hospital was trying to implement, and the nurse being fatigued a grave error was made. Instead of the nurse giving the patient a IV with penicillin in it, she gave an IV of anesthetic medication that was intended for her epidural. This eventually resulted in the patients death (AHC Media, 2015). This story is an example of an error that could possibly have been avoided, if the nurse had not been fatigued from working so many hours in a short

The medication error involved an 85 year old female. She was discharged from the hospital after an open reduction and internal fixation surgery for a fractured hip. Upon her arrival to the nursing home facility, there were multiple opportunities to prevent the medication errors that eventually lead to her fatal cardiac arrest. There was a lack in communication between the patient’s medical team. After the patient was discharged there was no follow up from the hospital nor a nursing care plan at the patients’ nursing home. The individuals did not use any critical thinking skills in going beyond the five rights of medication administration. There may have been a lack of knowledge of the medication. Since the patient had a history of

A major concern or challenge of ABC hospital is a recent incident of medication administration error in its emergency room (ER) which almost resulted in the death of a 55-year-old female patient. This is a case of medication administration through the wrong route. The Food and Drug Administration (FDA) defines a medication error as "any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding;

“The definition of a health professional is a person who works to protect and improve people’s health by the diagnosis and treatment of illness to bring about a complete recovery from mental, physical and social perspectives, either directly or indirectly (Kurban, 2010, pg. 760).” Nurses in the community today have acquired an increasing responsibility to intervene with medical decisions. In the past, there were clear differences between nurses and doctors. It was more common for a nurse to be supervised directly under the physician. They are not just performing Doctor’s orders anymore. The nurse role in patient care has been widely expanded. Allegations against someone can be one of the most stressful moments of their careers. Negligence

Risk factors for harmful medication errors reported include the usage of institute of safe medication practices (ISMP) high alert medications, inaccuracy of delivery devices and during the prescription phase of the medication administration process. According to the Harvard Medical Practice study 30% (thirty percent) of patients with medication related injuries died or were disabled for more than six months. (Carlson, 2001, p.18.)

In the case scenario, the nurse did not apply her knowledge to check the correct adult dosage of methadone. Methadone is a narcotic pain reliever, similar to morphine (Hodgson, 2011). When administering narcotics, it is required to have someone co-sign the MAR sheet to double-check with you (by using the five rights). The nurse was not able to use her critical thinking when she administered methadone. If she was a trained nurse, she would have realized it right away that there is something wrong with the dosage amount. There is a big difference between milliliter and milligram.

Pharmacists’ main focus is to ensure patients have the best medication outcomes. However, Jessica Thompson never experienced this. Due to the laziest of the pharmacist and others, Jessica did not receive the help she was entitled to. First, the technician used the wrong percentage of sodium chloride solution and did properly check with the pharmacist to ensure it was the right dose. Second, the pharmacist did not follow up with the tech to ensure the correct medication and dosage was right even after seeing a spent bag, Third, the nurses and doctors should have noticed changes in Jessica’s vital signs and after her complaining about headaches. Clearly, interest was not in the patient.

Medication error is one of the biggest problems in the healthcare field. Patients are dying due to wrong drug or dosage. Medication error is any preventable incident that leads to inappropriate medication use or harms the patient while the medication is in the control of the health care professional,or patient (U.S. Food and Drug Administration, 2015). It is estimated about 44,000 inpatients die each year in the United States due to medication errors which were indeed preventable (Mahmood, Chaudhury, Gaumont & Rust, 2012). There are many factors that contribute to medication error. However, the most common that factors are human factors, right patient information, miscommunication of abbreviations, wrong dosage. Healthcare providers do not intend to make medication errors, but they happen anyways. Therefore, nursing should play a tremendous role to reduce medication error