Please write 300 word reply to discussion post below. Must include at least 2 scholarly peer reviewed sources AND one biblical integration. Directions for original post are here:
Watch the Medication Errors simulation, conduct your “interviews,” take notes, and prepare your recommendations. Post those recommendations as your thread in this Discussion, meeting all requirements for a Discussion thread. I will upload the transcriipt for the Medication errors simulation.
Post you will reply to:
Medication Errors In Hospital Pharmacies
With thousands of prescriiption medications and more over-the-counter medications available in the United States, (U.S.) it should not be surprising that between 7,000 and 9,000 people die annually from medication errors, and it is estimated that thousands more experience adverse drug interactions that are not reported (Tariq et al., 2022). Bright Road Hospital is investigating a medication error that unfortunately resulted in the death of an eight-week-old infant. The purpose of this investigation is to determine if medical negligence occurred and Bright Road Hospital’s liability, if any. In our investigation, we will review the elements of medical negligence, summarize key events learned from the parties involved, review all the information gathered, and then make recommendations. This investigation will be complex because it involves a death. Undergirding the investigation with a Biblical perspective will be helpful. James 1:5, it states, “If anyone lacks wisdom, let him ask God, who gives generously to all without reproach, and it will be given him” (Holy Bible ESV, 2001). Wisdom will be needed to ensure liability is assigned properly, if at all.
Summary of Situation and Interviews
Approximately six months ago an infant died at Bright Road Hospital (BRH) after receiving a lethal dose of an antibiotic. The investigation began with interviewing the parties involved in the intravenous medication preparation, Tatiana Velasco, Pharmacy Technician, and Barry Longmore, Pharmacist. Ms. Velasco received her certification as a Pharmacy technician approximately six months before the incident. She was new in her role at BRH but, according to Mr. Longmore, was bright and had a promising career ahead. An order came in, and Ms. Velasco processed and mixed the intravenous medication. She felt like she followed hospital procedures and was shocked and upset to learn the infant had died after receiving the antibiotic she mixed. Mr. Longmore corroborated her story but also provided insight on the standard process for medications before the medication leaves the pharmacy. Mr. Longmore reported that he was preparing to check the intravenous infusion because it looked cloudy. He was called away to prepare an order for an emergency department emergency before he could check the medication. When he returned, the medication had been dispensed to the floor and administered with fatal results. To get a clearer picture, Mr. Longmore and Ms. Velasco were interviewed together at a later date. Mr. Longmore assumed when the other pharmacist returned from lunch; he placed the unchecked medication in the outbox, which was subsequently picked up for delivery to the floor for administration. The other pharmacist did not check the log book to determine whether the medication had been checked. Hospital procedures require all medications prepared by a pharmacy technician to be checked by a licensed pharmacist. Through that discussion, it appeared that the process put in place failed, and the medication left the pharmacy without being checked by a pharmacist.
Medical Negligence in Medication Dispensing
Four elements must be satisfied to substantiate a claim of medical negligence. The first element is an established duty to provide care, as evidenced by the pharmacy agreeing to provide the medication for the patient’s treatment. In the second element, the plaintiff must demonstrate a breach of duty or simplified, a demonstration that the expected standard of care was not followed, as evidenced by medication being improperly mixed and the medication leaving the pharmacy before being checked by a licensed pharmacist. The third element is causation, sometimes called the “so-what” clause, which means the defendant must show a direct correlation between the alleged mistake and an injury (Bal, 2009). In the case of the BRH, causation was demonstrated because the infant died. After all, a fatal dose of antibiotic was delivered and administered. Additionally, because of a direct correlation between the action of the pharmacy to the injury (death of the infant), it is a proximate cause (Bal, 2009).
Recommendations
Through a careful investigation which included interviews with the principal employees involved in the medication error, all of the elements of medical negligence were satisfied. Based on this, the hospital does have liability in the incident. However, before making recommendations, the concept of foreseeability must be explored. Foreseeability requires the plaintiff to demonstrate that the injury (death) was foreseeable by any reasonable provider as the likely result of the breach of duty (Paterick, 2022). In this case, foreseeability is established. Considering medical negligence did occur, the hospital is liable for the infant’s death and should pay damages. Settling out of court would be the best option if the family is agreeable.
Conclusion
The tragic events occurred at BRH due to failed processes within the pharmacy to ensure accurate preparation and safe delivery of the correct medication to a medical unit in a hospital. Hospital pharmacies have a lot of employees and a busy practice that frequently has emergencies that occur and need an immediate response. For this reason, adequate measures to check and recheck should be taken, documented, and communicated to the staff. Adherence to the guidelines should be strictly enforced. A series of checks and balances could help prevent disasters like the one at Bright Road Hospital.
References
ESV Bible. (2001). Crossway.
Paterick, T. E. (2022). Medical malpractice: An introduction to tort law. Journal of Professional Management, 37(4), 197-201. https://www.proquest.com/docview/2702261526/fulltextPDF/C4EF7C147BAE41E7PQ/1?accountid=12085Links to an external site.
Tariq, R. A., Vashisht, R., Sinha, A., & Scherbak, Y. (2022, January). Medication dispensing errors and prevention. Stat Pearls. https://pubmed.ncbi.nlm.nih.gov/30085607/Links to an external site.
