The issue of medical errors presents a serious public health problem that threatens the safety and wellness of patients. The number of patients who die because of medical errors each year has been a controversial topic ever since the movement of patient safety was initiated. As cited by Anderson and Abrahamson (2017, p. 13), medical errors account to over 250,000 deaths per annum in the United States, which rates the issue as the third leading cause of mortality. Despite the high numbers of mortality attributed to medical errors, it is astonishing that only about 10% of these cases are publicized or reported (Waeschle, Bauer, & Schmidt, 2015, p. 689). Although this could adversely expose caregivers and initiate litigations from the affected patients and families, publicizing medical errors could enhance professionalism and safety, while reducing such occurrences.
In 2014, a medical error occurred at St Charles Bend, causing the death of a woman aged 65. Loretta Macpherson had visited the hospital seeking for medication after experiencing anxiety barely two weeks after she had gone through a brain surgery in a hospital at Seattle. After going through the diagnostic processes, the medical staff at St. Charles determined that she required an intravenous medication known as fosphenytoin. Rather, she was administered with a wrong medication that contained a paralyzing agent. The medication is known as rocuronium, which affected her breathing ability. She later experienced a cardiac arrest that led to an irreversible damage of the brain. She died two days after the administration with the paralyzing agent.
Although making errors is a human nature, the reason a pharmacist included the wrong medication on the IV bag remain unknown. The nurse who was taking care of Ms. Macpherson ordered an anti-seizure drug, which was received correctly at the pharmacy department. This was in accordance with the findings of the electronic medical records. Instead of putting the correct medication, the pharmacistplaced a paralyzing agent and labelled it as an anti-anxiety drug as indicted in the prescription. Since the label on the drug indicated the correct prescription, Loretta’s caregiver could not discover the mistake and went ahead and administered the mediation to her patient (Bannow, 2014). After treatment the fire alarm went off, and the caregiver closed the doors to prevent her from fire. After twenty minutes, the nurse in charge realized the medical error, but it was too late to reverse the adverse effects of the drug.
As anyone would expect, the news about the medication error were received with anger by Macpherson’s family. One of her sons who had been taking care of her said that the family realized about the mistake after the mother went into cardiac arrest. They immediately demanded for an explanation from the hospital, which took several days before it could give a comprehensive and informed report(Bannow, 2014). Although this was not the reason, the family thought that someone had administered the medication and closed the door to prevent her from seeking help. The family went public about the issue and almost all media outlets became aware. They believed that publicizing the issue would lower the rates of medication error and if possible ensure that no other family experiences such pain and suffering. To establish punitive measures to the hospital as a whole, the family also went to court. Hospitals should protect the lives of their patients by ensuring that safety precautions are observed.
Understanding the organizational structure should reveal how the problem occurred and how it could be prevented in future. In Macpherson case, the nurse in charge realized that a medical error had occurred. Although exact details of how the problem escalated through the chain of the hospital command are not provided, it is evident that the nurse in charge tried to understand the cause of convulsions and cardiac arrest. After investigating, the nurse found that the content in the IV bag was different from what she had prescribed (Bannow, 2019). She reported to the nurse manager, who informed the day-to-day operation’s manager who escalated the case the clinical informatics. The information was then passed to both the chief information officer and the chief executive officer, Mr. Boileau. In this case, the hospital’s administrator had the role of g informingthe family about the medication error.
Incidences of medical errors can affect the organizational metrics of the administrator in a various ways. First, they affect the patient’s outcomes. Secondly, they increase the period of hospitalization and hence increase the cost of medication. Persoanally, I believe that the board of trustees should be relayed with the exact details of how the medication error occurred. In such a highly publicized issue, communicating the information partially could lead to mistrust from the board of trustees who have the responsibility of overseeing the hospital operations. In fact, such an issue could not have been solved without the boards input since they play an integral role in the management of the organization. Therefore, ….
References
Anderson J. G., & Abrahamson, k. (2017). Your health care may kill you: Medical errors. Studies in Health Technology and Informatics. 234: 13-17.
Bannow, T. (2014). The bulletin: Error at St. Charles bend results in patient’s death. The Union Democrat.Retrieved from https://www.bendbulletin.com/localstate/2654383-151/error-at-st-charles-bend-results-in-patients?entryType=0#
Bannow, T. (2019). St. Charles bend admits mistake led to patient death. The Union Democrat Retrieved from https://www.uniondemocrat.com/newsroomstafflist/2655694-153/st-charles-bend-admits-mistake-led-to-patient
Waeschle, R. M., Bauer, M., & Schmidt, C. E. (2015). Errors in medicine. Causes, impact and improvement measures to improve patient safety. Anaesthesist. 64(9):689-704
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