Case of Missing Safety: Medication Errors, Ethical Principles, and Legislation

Running head: CASE OF MISSING SAFETY
CASE OF MISSING SAFETY
Name of the Student:
Name of the University:
Author note:

1CASE OF MISSING SAFETY
Topic 1: Medication Errors
Factors of Medication Related Error
The primary medication error which occurred Mrs. D, was a lack of adequately
mentioning the requirement of warfarin in the discharge education as well as discharge
medication plan of the patient. Considering the associations between aggravation of
cardiovascular symptoms and emergence of thrombus formation resulting in disruption of blood
circulation for cardiac functioning - regulation of coagulation functioning is of utmost
importance (Martinelli et al., 2016). For this reason, adherence to anticoagulant therapy and
warfarin medications is of utmost importance for Mrs. D. However, it can be observed that the
need for warfarin medications was noted only by the allocated physician but not communicated
to the clinical staff. Hence, this lack of communication resulted in a medication error resulting in
lack of disseminating discharge education to the patient on necessary warfarin intake and
avoidance of INR monitoring (Roughead, Semple & Rosenfeld, 2016).
A key factor underlying the occurrence of a medication error is the lack of adequate
communication between health professionals as well as between health professionals and the
patient. Patient care is a composite of contributory efforts from all health professionals hence
prioritizing the administration of a multidisciplinary approach (Murray et al., 2017). A key factor
underlying prevention of medication errors is the execution of a multidisciplinary approach
where information concerning patient’s needs must be relayed across all health professionals.
Hence, it the key contributor of Mrs. D’s medication error is the lack of communication between
the physician and the clinical staff on the need to continue with warfarin medications and INR
screening (Alex et al., 2016). Additionally, communication between health professionals and

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patients, especially during discharge, is of utmost importance since the same enlightens patients
on necessary interventions to adhere to post clinical interventions. It can be observed that Mrs. D
was only communicated on intake of routine pain medications hence resulting in lack of warfarin
intake and her fatal progression towards cerebrovascular accident (O’Riordan, Delaney &
Grimes, 2016).
NSQHS Standard 4 Action
In order to prevent the occurrence of medication error as observed in Mrs. D, the nurse in
care can adhere to the NSQHS Standard of 4.11, which outlines ‘Information for patients’
(NSQHS Standards, 2019). As per this standard of care, health professionals such as nurses and
clinicians must educate and communicate the patients the need to adhere to required medications,
the availability of various medications and the advantages as well as risks associated with each
medication (Ritchie et al., 2018). From the case study, it can be observed that a key contributor
underlying occurrence of medication error is Mrs. D as well as the clinical staff, not being
communicated on the need to adhere to warfarin intake – hence indicating a violation of this
standard. Hence, to prevent the same the nurse must adhere to this care standard by first
implementing Action 4.2 – which includes providing Mrs. D a patient centered discharge
containing a list of all required medications as per her clinical condition (like warfarin) as well as
a section on available health services with whom she may discuss her medications (Gilbert et al.,
2017). This standard will also require the nurse to adhere to Action 4.13 which will include
usage of a multidisciplinary approach and collaboratively communicating with Mrs. D’s clinical
staff and physician on the need to have access and comply with evidence-based, patient centered
medication information unique to Mrs. D (Trevena et al., 2017). It will also include Action 2.4
requiring obtaining Mrs. D’s consent on intake of her current plan of pain medication as well as

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evaluation of medicine information which would monitor the presence of adequate
documentation of Mrs. D’s medications at all organizational and multidisciplinary professional
levels (NSQHS Standards, 2019).
Topic 2: Ethical Principles
Beneficence
The nursing ethical principle of beneficence outlines that nurses must seek to deliver care
and quality practice for the purpose of ensuring good or benefit to the patient. Hence to ensure
that the same, the nursing formulation of priorities of care and treatment must ensure that the
benefits or possibilities of achieving positive health outcomes in the patient are provided to the
maximum potential so that no form of harm of conductance of nursing maltreatment befalls in
the patient (Pope, Hough & Chase, 2016).
Non-maleficence
For the purpose of ensuring quality nursing practice and ethical compliance, the nurse
must engage in the ethical practice of non-maleficence. The practice of non-maleficence, implies
that the nurse must ensure deliverance of appropriate care and treatment practices which will
inflict no harm or the least possible harm to the patient, considering that every clinical action
exerts its own set of benefits and shortcomings (Ong-Flaherty et al., 2016).
Application
Hence, in terms of the case study of Mrs. D, to apply the ethical principles beneficence,
the nurse in care should have ensure that the ongoing care as well as the discharge plan and
education provided to the patient is directed for the benefit of Mrs. D, so that she recovers from