Legal and Ethical Issues of a Medical Error Case - Essay Example

?Legal and Ethical Issues of a Medical Error Case The case scenario I selected is the case about the death of a day old infant in 1996 at Denver hospital, which provides an example of one of the most serious and prevalent causes of negligence medication error. The paper will also point out the people who were liable of the errors, ethical standards not adhered to, as well as effects of disclosing. The paper also focuses on impacts of the medical errors ways can health care administrator help prevent the kind of error described in the scenario from happening. The case resulted due to several assumptions made in matters that were unclear to the nurse. The infant was born to a mother with a history of syphilis. The infant’s parents were Spanish which deterred proper communication due to language barrier. Due to lack of proper information on the previous treatment received by the mother, the physician, nurses and pharmacist assumed the baby had congenital syphilis. The treatment for congenital syphilis entails administration of Benzathine penicillin G 150,000U IM and the hospital staffs were unfamiliar with this drug. The pharmacist who filled the order misread the infant dose for penicillin G benzathine as 500, 00 units/kilogram which is supposed to be an adults dosage instead of infants dosage of 50,000 units/kg. Using the misinterpreted data, she prepared a 10 fold overdose of 1, 5000, 000 units which was to be dispensed in a 2.5 millilitres injections intramuscularly. The hospital lacked the structure for double-checking thus the error was not noticed (Aspden, 2007). The nurses received the erroneous medication became concerned since babies can only get 0.5ml per injection. They felt that the five injection required to administer the medication were too many. They thus chose to consult sources for possible intravenous administration of penicillin G benzathine and erroneously concluded that it was the same drug as crystalline penicillin G, which could be injected intravenously and thus administered the drug through IV. The milky colour of the drug did not tip off the nurses to find out more information as much as they were aware that coloured drugs were rarely injected intravenously. The syringe used was meant for intramuscular injection but due to poor labelling by the manufacturer the nurses did not notice the label thus administered the lethal drug intravascular, which eventually led to the death of the infant since the airways were obstructed by the drug. This resulted in suing of the three nurses who administered the drug (Aspden, 2007). The laws broken include poor management of faulty information since the nurses insisted on using the poor understood information. Most of the errors were system base particularly the lack of double-checking. Another issue was the propensity of making assumptions, and incomplete clinical information, which led to erroneous diagnoses of the infant with congenital syphilis. Another law that the hospital failed to abide to is the requisite education of staff before they administer nonformulary drug. The hospital also lacked patent clarity of prescriptive power for nonphysicians thus the nurses changed the route of administration without consulting a physician. The health provider failed to adhere to some ethical standards, which affected the patient outcome. Some of the mistakes that occurred in this case were inevitable such as the language barrier. However, adherence to medical ethical would have eliminated some occurrences. The failure to follow the proper diagnosis procedure contributed to the whole scenario since the infant was treated for the wrong disease. Happenings such as the wrong administration route could have been avoided since it resulted due to violation of the rule that requires nurses to check with physicians before making such changes. Other errors that could have been avoided include failure of nurses to question the prescription, the nurses did not enquire from the pharmacist when they could not recognize the drug appropriately. All the above affected the patient being treated for that the wrong disease, erroneous dosage and erroneous administration route. The communication strategies on the drug order were nonstandard. Had the caregivers bothered to clarify the information as the ethical standard demand, the occurrence would have been evaded or at least the chain would have been broken and the consequences would have been different (Aspden, 2007; Naylor, 2002). In the case I have analysed, the interaction between the care provider and the deceased infant family if not emphasized on. However, an autopsy was done and confirmed that the infant had been erroneously diagnosed with congenital syphilis leading to the flawed treatment. After the erroneous death of the infant, the nurses involved were prosecuted and arraigned on for infant negligent homicide. Two of the nurses admitted the negligence and pleaded guilty while the other nurse went to trial. The jury acquitted the nurse who was tried. However, a lot of blame game was evident all through the trial but it was clarified that the caregiver handled the case with extreme casualness, which prevented detection of the error prior to reaching the infant. There are pros and cons of having the provider disclose and apologize for the error to the patient or family soon after the occurrence. One of the advantages is that the external pressure is reduced since the transparency leads to increased chances of handling the case without ligation. The disadvantage is that the family of the patient may be uncharitable and exceptionally publicise the issue which may work negatively on the reputation of the institution as well as the staff members involved (McClanahan, Goodwin, & Perlin, 2010; Aspden, 2007). The legal implications include probable suing of the staff members involved in the blunder, which may lead to sacking or even imprisonment. The ethical implications of this approach may be positive or negative. If the case is publicised, the institution may lose credibility. If the family accepts to deal with the issue silently, the effects could be minimal but it could encourage transparency and accountability amongst the staff members (Cohen, 2007). Generally, transparency would be a positive approach since it would create a sense of indulgent towards the caregiver. The approach would also promote accountability of the physicians, nurses, technicians, or others who may have contributed to the medical error that harmed a patient. (Hepler & Segal, 2003). The health care administrator can help prevent the kind of error described in this scenario from happening in the first place. This could be by clearly defining the prescriptive authority particularly for nonphysicians, ensuring the products and equipments used are plainly labelled. The hospitals should also provide sufficient and up to date sources of reference on drug types and their administration, sufficient training of pharmacists is important to enable them detect error when preparing dosages. There should also be limit dose warning systems to detect overdoses such as in the above case. Consistent pharmacy, and drug administrative procedures need to be developed (Banja, 2004; Young, Koopsen, & Farb, 2005; Rice, 2002). The above measures can assist the providers and organization to determine the cause of the errors, the negligence level, and the strategy of dealing with such errors when they occur. The measure can also aid in improvement of information access thus decrease reliance on caregiver’s memory, reduce the level of the chances for errors, develop a standard way of operations such as prescription, diagnoses and drug administration. The measure would also reduce frivolous attitude during handling of drug, administration, as well as prescription, and encourage apposite criterion for task management. Enacting the above measure would help health care professionals realize the importance lessening avoidable errors for safer patient care (McClanahan, Goodwin, & Perlin, 2010; Rice, 2002). References Aspden, P. (2007). Preventing Medication Errors. Washingto D. C.: National Academies Press. Pg.44-49. Banja, J. (2004). Medical Errors And Medical Narcissism. New York: Jones & Bartlett Learning. Cohen, M. (2007). Medication Errors. New York: American Pharmacist Associa. Hepler, C., & Segal, R. (2003). Preventing Medication Errors and Improving Drug Therapy Outcomes: A Management Systems Approach. London: CRC Press. McClanahan, S., Goodwin, S., & Perlin, J. (2010). The Basis of Patient Safety. Retrieved June 23, 2010, from http://media.wiley.com/product_data/excerpt/01/04705024/0470502401-286.pdf Naylor, R. (2002). Medication Errors: Lessons for Education And Healthcare. San Diego: Radcliffe Publishing. Rice, J. (2002). Medications and Mathematics for the Nurse. Stanford: Cengage Learning. Young, C., Koopsen, C., & Farb, D. (2005). Medication Errors Guidebook. Los Angeles: University Of HealthCare. Read More