Medication Error: Case of Mrs May & Nurse Sarah - Research Paper

Introduction

The medication error case study involves Mrs May and her nurse Sarah. Sarah claims that she gave her patient more than twice the chemotherapy dose she was to be given. According to Sarah, this happened some weeks to Christmas after she had completed her Bachelors of Science in Nursing. Although Mrs May had been a patient at the facility for almost a year after been diagnosed with cancer, Sarah had not yet met her (Sorrell, 2017). On meeting her, Sarah introduced herself to the patient and administered the chemotherapy. The chart got removed from the clinic before Sarah could record the dosage she administered to Mrs May.

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Sarah recalled that she had not recorded the dosage and decided to check on the chart to record. On looking at the oncologist dosage of medication, Sarah realized that she gave the patient two and half times the required amount. Sarah claims that the drug was new to her and that it was also ordered in a specific format that made her get confused on the dosage versus the dilution of the medication. On reporting the error to the oncologist, he said that he would treat the patient aggressively to increase her cell counts (Sorrell, 2017). Sarah made Mrs May aware of the error she had made, and even though the patient got very sick for about two weeks, she told Sarah she will make and as of the date she is still alive and doing well.

Analysis of the Medication Error(s) in the Situation as It Affects Patient Care

Even though Sarah was a careful, caring and competent nurse, she ended up making some medical errors that could have almost killed Mrs May. Sarah's story shows that medical errors are not just as a result of incompetency or negligent of the healthcare professionals but can also be due to the breakdown of the processes guiding the delivery of caring for the patients as in case of Sarah. The medication errors from Sarah's situation include; first, improper dosing error: this type of error occurs when the patient is given a greater or a lesser amount of the required medication to manage the condition the patient is suffering from. In case of Sarah, she gave Mrs May 250mg instead of the needed 100mg; she gave the patient two and half times the ordered amount something which made the patient fall very ill for about two weeks and could have killed her had Sarah not noticed the mistake before it was late(Sorrell, 2017). Sarah's error was because the medication was very new to her and also the format ordered made Sarah confused on the dosage versus dilution of the medicine.

Second, wrong drug preparation error: this error happens when there is an incorrect formulation of the medication. It involves more or less diluting of the solution during the reconstitution of the medication. As in the case of Sarah, she diluted the medicine wrongly as she states that she remembers reconstituting 4 vials and ended up giving twice and half of the required amount (Sorrell, 2017). Hence the need to use clear and consistent formats to enable the person administering the medication understand the dosage and dilution with ease because the wrong dilution can lead to various complications on the patient or even threaten their lives.

Third, fragmented case error: this results when there is no communication between the physician involved in the prescription and the administering healthcare professional. In Sarah's situation, she did not have accesses to the medical record, where the medication administration prescribed by the oncologist was recorded (Sorrell, 2017). It was removed before she could have access to it; hence she lacked a vital safety check which if she had, she could have administered and recorded the correct dose. She would have avoided putting Mrs May's life in danger.

Description of Legal and Ethical Consequences Surrounding the Medication Error and Application of the American Nurses' Association (ANA) Ethical Standards

Beneficence and No maleficence: these principles direct all the healthcare providers to ensure that they do the best for every patient and avoid causing any harm, whether intentionally or unintentionally. These principles often result to various moral conflicts for the healthcare providers in their workplace since they face challenges in trying to balance the estimated benefits which possess some possible risks to the patients (Sorrell, 2017). Although these errors differ on their severity, every error has significant harm to the patients to the system as well as the individual who caused the error. It is, therefore, essential for all the healthcare providers to practice safe steps to avoid causing medical errors (Ghazal, Saleem & Ariani, 2014). As in the case of Sarah, she might have thought that if she informed Mrs May of the error she had committed, she would cause some unnecessary suffering and worries to her. However, had she not told the oncologist about the error, the patient would not have been treated aggressively to offset all the potential harms.

Autonomy and right to self-determination: these concepts acknowledge the rights of the patients to make their own decisions and take any actions on the basis of their perceived benefits and personal views. The healthcare provider has an ethical obligation of informing a patient the current treatment plan, including any medical errors which might have occurred (Ghazal, Saleem & Ariani, 2014). If Sarah did not take the initiative of informing other individuals of the error she had made, Mrs May could not have made proper decisions on the treatment, which was necessary to prevent the potential harm. The first provision of the American Nurses Association Code of Ethics for Nurses (2016), states that "The nurse practices with compassion and respect for inherent dignity, worth and unique attributes of every person" (ANA, 2016). It involves patient's right to self-determination, where as well as the healthcare provider's relationship with the patients. All healthcare should help patients when it comes to making decisions concerning their treatment as the oncologist did to Mrs May. The oncologist was honest to the patient about the error and the necessary treatment to offset the potential harm.

Veracity: This principle directs the healthcare providers to offer accurate objective and comprehensive information in a way that will help the patients get the information. When healthcare providers tell their patients the truth, establishes the trust (Sorrell, 2017). The physician and Sarah's careful communication with Mrs May established trust, which can be seen in the mutual respect between Mrs May and Sarah, which they shared even after the incidence and treatment.

Disclosure and right to knowledge: the healthcare provider is obliged to disclose any information needed by the patient during informed decision making. Ghazal, Saleem & Ariani 2014 states that the patient's bill of rights advocates for disclosure of any medical error. Mrs May was fortunate since her healthcare providers disclosed the error committed by Sarah to her hence decreasing the possible harm and showing respect to her autonomy(Sorrell, 2017). There is need for health institutions to have detailed and transparent policies of disclosing information about medical errors.

Methods Used to Decrease This Type of Medication Error

Sharing stories about the errors: practitioners, as well as students, should be encouraged to share their different stories about medical errors instead of hiding such stories because of fear. Sharing these stories helps shift peoples thinking from scientific and rational to reflective patterns of thinking which calls for detailed information which surrounds these experiences (Sorrell, 2017). Sarah's situation accurately illustrates this context because we can see she recalls how she forgot recording the medication administered to her patient. She explains about her fears of Mrs May losing her life, the trust she had to the healthcare system as well as losing her license.

Document everything: documentation involves legible documentation of the administered medication and labelling of all the medicines. Failure to properly document all the drug can cause medical errors (Ghazal, Saleem & Ariani, 2014). For instance, in the case of Sarah, she forgot, documenting the medication she had administered. Such errors can lead to another medication been administered to the same patient due to lack of documentation which denotes the preceding administration.

Conclusion

Medical errors are among the major causes of patient's deaths in the world today. These errors are not just as a result of incompetency or negligent of the healthcare professionals but can also be due to the breakdown of the processes guiding the delivery of caring for the patients. The ethical principles governing healthcare providers help in minimizing these errors. It is also crucial for the healthcare systems to set proper rules and policies to help to avoid medical errors since these errors can have significant effects on the patients.

References

American Nurses Association (ANA). (2016). American Nurses Association calls for a culture of safety in all health care settings. Retrieved from https://anacalif.memberclicks.net/assets/Events/RNDay/2016%20code%20of%20ethics%20for%20nurses%20-%209%20provisions.pdf

Ghazal, L., Saleem, Z., & Ariani, G. (2014). A medical error: To disclose or not to disclose. Journal of Clinical Research & Bioethics, 5(2). Retrieved from doi:10.4172/2155-9627.1000174

Sorrell, J. M. (2017). Ethics: Ethical issues with medical errors: Shaping a culture of safety in healthcare. OJIN: The Online Journal of Issues in Nursing, 22(2).Retrieved from http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/Columns/Ethics/Ethical-Issues-with-Medical-Errors.html