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Preventing Errors for Healthcare Professionals: Summary
Error in the Medication Process A 41-year-old female was ordered 160 mg daily of Temodar. The dosage was 20 mg in each capsule, so she was instructed to take eight capsules daily. However, the medication that the patient received from the pharmacy was a 250 mg capsule rather than the intended 20 mg capsules, and she administered eight capsules for a total daily dose of 2,000 mg. The patient presented with pancytopenia and died 10 days following administration of the last dose. Lucinda Lucinda and her husband were at an initial appointment with Dr. Richards, a chiropractor, after Lucinda had continued to have low back discomfort following the birth of their daughter. Dr. Richards did a subjective history, took X-rays, and performed a manual examination. Then he called Lucinda and her husband into his office. He informed Lucinda of the problems that she had in her lower back and recommended a plan of care. The plan of care extended over a 6-month period, consisting of heat therapy and manipulation along with repeated X-rays. By the second month, office visits were required every other day. Lucinda did not have health insurance and could not cover the $10,000 medical bill. Lucinda attempted to negotiate a payment plan with Dr. Richards, but the doctor was unwilling to work with her. He advised Lucinda that treatment could not continue until payment was received. Sue Sue is an occupational therapist at Gulf Coast Therapy Associates, located in Bates County, Missouri. She has just completed an intake on Frank Simons for therapy after a work-related accident at Exxon Mobil Refinery. The Bates County public health agency receives information that a person infected with a contagious bacterium by the name of Frank Simons is being treated at Sue’s facility. On the one hand, Sue and the facility have a duty to respect Frank’s right to confidentiality and freedom of movement. However, the occupational therapist and Gulf Coast Therapy Associates have a greater duty to prevent the spread of the bacterium to other people. In the utilitarianism approach to ethics this is known as “doing the greatest good for the largest number of people.” Thus, more good would be achieved by protecting the public health of all the other patients treated at Gulf Coast Therapy Associates. This can be accomplished only by breaching Frank Simon’s Sheralyn Sheralyn walked into the emergency department (ED) one Monday morning in October unable to breathe. Preliminary tests were performed, objective data were collected, and a detailed subjective history was taken. Time went by, but a diagnosis eluded the attending physician. She was given a dose of Lasix as a preventative measure, in case her shortness of breath was related to congestive heart failure. Finally, all the tests were returned and the physician was able to determine that Sheralyn had two massive pulmonary embolisms (one lodged in each lung). But why? She was overweight and had a sedentary lifestyle but was otherwise in average health. Throughout the day, various doctors, nurses, and other medical staff had taken a subjective history on Sherlyn in the ER as well as collecting objective data. They all missed one key item. She had been prescribed Megace, a coagulant, 18 months earlier. Sherlyn had faithfully itemized medications she was on to every medical professional for the last 24 hours, but no one caught it.
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