Legal and Ethical Issues of a Medical Error Case
In the case study “Understanding the Causes and Costs of Medication Errors”, a Denver hospital acknowledged that a medication error had led to the death of a day-old infant, born in 1996 to a mother with a prior history of syphilis. Because the patient’s parents spoke only Spanish, communication was difficult. This factor, coupled with the fact that the hospitals’ physicians, nurses, and pharmacists, were unfamiliar with the treatment of congenital syphilis and had limited knowledge about the drug, led to the ultimately deadly penicillin dose. Evidence in the case showed that more than 50 latent and active failures had occurred throughout the medication-use process, such as poor syringe labeling, pharmacy mistakes, and confusing drug information (National Research Council, 2007).
The three nurses responsible for treating the patient were later charged with negligent homicide.
Legal Aspects of this Case
Four elements must be present for negligence; duty to care, breach of duty, injury, and causation. Negligence is a civil personal wrong of unintentional commission or omission of an act a reasonable prudent person would or would not do under similar circumstances (Pozgar, 2013).
According to the National Coordinating Council for Medication Error Reporting and Prevention, a medication error is “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 (2014).” Though technically, no federal laws were broken in this case, death could have been prevented had the nurses noticed the 10-fold overdose or the manufacturer’s label on the syringe reading “IM use only”. The U.S. Food and Drug Administration (FDA) and the Institute for Safe Medication Practices (ISMP) state that some abbreviations, symbols and dose designations are frequently misinterpreted and lead to mistakes that result in patient harm (FDA, 2006).
The Essay on Medication Errors 3
Approximately, 1.5 million people are injured in the United States due to medication related errors. Errors involving prescription medications kill up to 7,000 Americans per year, according to the Institute of Medicine, and that the financial costs of drug-related morbidity and mortality may run nearly $77 billion a year. FDA also reviews about 1,400 reports of medication errors per month. Before ...
Therefore, it is the legal responsibility of the FDA, healthcare professionals, medical students, medical writers, and the pharmaceutical industry to eliminate the use of potentially confusing abbreviations in order to prevent cases such as these.
Ethical Standards and Patient Outcome
The purpose of the American College of Healthcare Executives (ACHE) code of ethics is to serve as a standard of conduct and standard of ethical behavior for healthcare providers in their professional relationships (ACHE, 2012).
Numerous ethical issues could arise as a result of medication errors; such as harm to patients, whether to disclose the error, erosion of trust, and impact on quality care. However, most of what health care providers practice is governed by the system within which they act. For instance, it was mentioned in the case study that while hospital policies and practices gave prescribing authority to nurse practitioners, they did not clearly define such authority in terms of the ability to change prescription orders. “However, the neonatal nurse practitioner assumed that she was operating under a national protocol that allows neonatal nurse practitioners to plan, direct, implement, and change drug therapy (National Research Council, 2007).” This case is a clear illustration of how medication errors are almost never the fault of a single person or caused by the failure of a single element. Therefore, the authorities in this case decided against the inclination to focus on the misguided efforts and errors of the nurses and other providers, and determined that they had not been under their control alone. “Had even one of these failures not occurred, the accident would not have happened and the error would have been detected and corrected before reaching the infant (National Research Council, 2007).”
The Term Paper on Improving Patient Care
... as the effectiveness of communications across care providers as measured by patient outcomes (e. g. , reduction in medication errors, lower readmission rates) could potentially generate ... that is the case. In summary, the EMR is a promising tool for improving quality of care in primary care and other health ...
Provider Disclosure
The post-error period following the death of a patient is the most a demanding time for everyone involved. In this particular case, there was no mention of how the provider interacted with the patient or family after the error came to light. However, in most cases there are pros and cons of having the provider disclose and apologize for the error to the patient or family soon after the occurrence. Even in the finest of health care organizations, the fear of increased legal liability that comes along with the disclosure of a medication error is substantial. Disclosure is especially difficult for hospital care providers, because they often don’t have all of the necessary information readily available to provide an explanation to the family immediately. For instance, in this case it was not until an autopsy was performed that it was confirmed that the baby had not had congenital syphilis as clinicians initially thought, and therefore never needed treatment in the first place. That being said, even the most well-intentioned and remorseful doctor may fear having their statements used against them in malpractice suits.
Prevention
There are many lessons to be learned from this case. Numerous factors in the health care system contribute to medication safety and errors. Some of these factors can be attributed directly to provider organizations, while others can be attributed to the medication-use system itself (National Research Council, 2007).
Although in this case it was nearly impossible to place blame upon any one person involved in the death of the patient, it is that we take from this a new responsibility as health care administrators to focus on the multiple underlying system failures that shape individual behavior and create the conditions under which medication errors occur. Providing a prime level of medication and prescription safety requires that we not only recognize, but correct the hidden botches in the system.
The Essay on Risk Management Medication Errors
Risk management paper Risk management is defined as a program directed toward identifying of, evaluating of, and taking corrective action against potential risks that could lead to injury of patients, staff, or visitors. It is a planned program of loss prevention and liability control, and its main purpose is to identify, analyze, and evaluate risks and then to develop a plan for reducing the ...
References
American College of Healthcare Executives. (2012).
ACHE Code of Ethics. Retrieved From: http://www.ache.org/abt_ache/code.cfm
Food and Drug Administration. (2006).
FDA and ISMP Launch Campaign to Reduce Medication Mistakes Caused by Unclear Medical Abbreviations. News & Events. Retrieved From http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2006/ucm108671.htm
National Research Council. (2007).
Understanding the Causes and Costs of Medication Errors (Case on the death of the day-old infant).
Preventing Medication Errors: Quality Chasm Series. Washington, DC: The National Academies Press. Retrieved From http://books.nap.edu/openbook.php?record_id=11623&page=43.
National Coordinating Council for Medication Error Reporting and Prevention. (2014).
Retrieved From http://www.nccmerp.org/
Pozgar, G. D. (2013).
Legal and ethical issues for health professionals. Burlington, MA: Jones & Bartlett Learning.
