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 ...view middle of the document...
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 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...