Case Study Analysis

This is a report on a case of claimed administration of the wrong medication resulting in the premature delivery of a fetus. The report includes an ethical and legal assessment of the case, recommendations for the healthcare organization, and procedures to prevent similar situations in the future.

Running head: CASE STUDY ANALYSIS
Case Study Analysis
Name
Institution

CASE STUDY ANALYSIS 2
Executive Summary
Following the recent case, I did a comprehensive investigation on how the current
situation can be handled and future occurrences prevented. For management of the current case
the facility should foot the baby’s medical bills using the defendant pharmacists pay and subject
the co-defendant nurse to disciplinary action. For prevention of future occurrences the facility
ought to ensure all participants double checked by an additional pharmacist, before giving out,
for added safety. Pharmacists should always consult with the pharmacy director whenever need
arises. They should also contact the prescribing physician for any questions the former may have
in relation to the ordered medication or clarification on the drug details.
Introduction
This is a report on an occurrence that transpired in the facility some time back. The report
comprehensively covers a vivid description of what occurred, the parties involved, the person(s)
affected and why the incident happened. Additionally, the report covers my assessment of the
case in the perspectives of ethical and legal concerns. It also provides suggestions on how the
case can be managed from the perspective of the healthcare organization. The report also
highlights my opinions on what could have been done to prevent this situation. Lastly, it have
recommended the implementations of procedures to prevent this from occurring in the future.
Description of the Case
This is a case of claimed administration of the wrong medication occasioning in the early
delivery of a 23 week old fetus with consequent brain impairment. The plaintiff was a patient 23
years of age who was heavy with a 23 week old fetus. She came to the healthcare facility with

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complains of slight vaginal bleeding and a supposed inadequate cervix. Consequently she was
admitted in the healthcare facility to the inpatient obstetrical unit for further necessary
observation and bed rest. On analysis and investigation of possible causes of the vaginal
bleeding, her physician recommended that she should be administered with a progesterone
suppository to discontinue the bleeding.
The defendant was one of the health facility’s pharmacists’ who, at the time of the
occurrence happened to be feeling unwell and had requested for permission to be relieved of her
duties that day. But then, the day happened to be a very busy one so she had to wait until the
pharmacist who was to step in for her to arrive. Two more hours elapsed and the relieving
pharmacist was yet to arrive. Consequently, the progesterone suppository order had to be
handled by the defendant pharmacist before her relief arrived. The defendant pharmacist
happened to be unacquainted with the ordered medication. She entered what she thought was the
accurate mnemonic for progesterone onto the health facility’s computerized scheme and the
medication Prostin appeared.
The defendant pharmacist assumed that Prostin was just a different name for the same
ordered progesterone suppository. She did not do a further investigation on the medication and
handed out the Prostin suppositories being certain it was a comparable prescription. The nurse in
charge of labor and delivery failed to ascertain the blunder and proceeded to administer the
Prostin suppository to the patient. Disastrously, Prostin is a medication used for the purposes of
cervical ripening and it is occasionally used to carry out abortion procedures. This means that it
delivers the exact opposite clinical outcome of the ordered drug. The patient went into active
labor and delivered a premature male infant at 23 week gestation. The infant was severely

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impaired, needed intubation and respirator provision and was moved to a specialized infirmary
where he is currently receiving over-all care.
The blunder was learnt the next day and disclosed to both the parents and the defendant
pharmacist. The defendant pharmacist was in agreement that she should have conducted an
investigation of the medication that was ordered since she was unacquainted with it. She
additionally agreed that during the entrance of the drug into the computer she failed to inquire
whether the medications were the similar and neither researched the medication names nor ring
the doctor responsible to explain the order. In the consequent lawsuit, both the hospital and the
nurse involved were termed as co-defendants.
Ethical Assessment of the Case
The defendant pharmacist failed to abide by the code of ethics for pharmacists. For
instance she failed to maintain professional competence which Baker (2016) denotes as an
offense. She had to be aware of the medication that was ordered since it is the pharmacists’
obligation to keep up acquaintance and skills as new suppositories, devices, and expertise
become existing and as health info progresses. Ignorance is not tolerated at all in the
pharmaceutical department (Brushwood & Smith, 2012). The defendant pharmacists should have
taken concern for her working practices by consulting about the progesterone suppository
bearing in mind that she remains liable for her decisions and work done. She was professionally
negligent by filing to research on the two medications and assuming that they are one and the
same thing. She failed to seek advice and further clarification on the ordered drug from the
physician concerned. However, the defendant pharmacist acted with honesty upon questioning
on the occurrence. She fully acknowledged her mistake and had to bear with the consequences

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that came with it. A pharmacist has a responsibility to tell the actuality and to act with persuasion
of ethics. However, tragic a case maybe, honesty is of key consideration in the pharmaceutical
practice.
Legal assessment of the Case
Generally, anybody and everybody who is involved in the prescription and administration
of medications are liable in a lawsuit for prescription medication blunders. This comprises of;
pharmacists, nurses, physicians, hospitals and healthcare facilities, the pharmacy divisions in the
hospitals, and the pharmaceutical company. In this situation the defendant pharmacist was
identified by the law as the most responsible for the occurrence; hence the defendant. She failed
to further investigate on the progesterone suppository ordered and made inaccurate assumptions
whose results were tragic. Both the nurse involved and the healthcare facility were named as co-
defendants in the consequent lawsuit. The nurse was possibly blamed for not cross-checking the
medication before administering to the patient. The health facility, on the other hand, was on the
wrong for filing to update their computerized scheme used to retrieve medications and the like.
Recommendations for how the healthcare organization can manage the case
In my opinion, the healthcare organization can try to manage the case in two main ways.
First the healthcare organization should ensure that the infant who was referred to a specialized
facility receives utmost care to improve his condition. This can be done through covering all the
medical costs and expenses incurred in the care of the baby. Footing of the baby’s medical bill
could be done using the defendant pharmacists’ full limit of her policy (Evans, 2016).

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Also the co-defendant nurse could be subjected to proper disciplinary procedures due to
failing to ascertain the medication before prescription as supported by (Singer & Fernandez,
2015). She ought to be relieved of her duties as the nurse in charge of labor and delivery and the
post given to someone else who can act more proficiently. Also a fraction of her salary should be
deducted monthly and sent to the infirmary where the baby is admitted to aid in covering for his
medical expenses.
What could have been done to prevent this situation?
To prevent this situation, the defendant pharmacist should have performed appropriate
research on the ordered medication which she was certainly unfamiliar with as encouraged by
(Fink, 2017; Krajnović & Jocić, 2017). Also, she ought to have followed the pharmacy
conventions when entering the drug order into the computerized scheme and only used ratified
mnemonics. If she would have followed the latter procedure, she would have realized that the
particular mnemonic was missing from the system hence preventing the situation from occurring.
The nurse in charge of labor and delivery, on the other hand, should have cross-checked the
medication to ascertain that it was the correct one before administration. On doing so, she would
have identified the blunder thus preventing the case from happening. The hospital management
could have ensured that the people in charge of the computerized scheme update it regularly.
Starr (2015) denotes that this way the mnemonic for the progesterone suppository could be found
in the system hence deterring the situation from happening.
Implementation of procedures to prevent a similar situation from happening in the future
In order to prevent a similar situation from happening in the future, the following procedures
should be put in place and implemented:

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1. All prescriptions should be double checked by an additional pharmacist, before giving
out, for added safety.
2. Pharmacists should always consult with the pharmacy director whenever need arises
(Webb, 2015).
3. Pharmacists should contact the prescribing physician for any questions the former may
have in relation to the ordered medication or clarification on the drug details (Fudin,
2016).
4. The healthcare facility management should ensure that each pharmacy computer has
comprehensive, current drug research within its programming and is automatically
updated.

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References
Baker, K. R. (2016). Can pharmacists be sued for doing their jobs? Drug Topics, 160(2), 38.
Retrieved from http://search.ebscohost.com/login.aspx?
direct=true&db=buh&AN=113146256&site=ehost-live
Brushwood, D. B., & Smith, W. T. (2012). Warranties of a compounding
pharmacist. American Journal of Health-System Pharmacy, 66(5), 495–498.
https://doi.org/10.2146/ajhp080409
Clinical trials - ethical and legal responsibilities of pharmacists. (2016). Journal of Pharmacy
Practice & Research, 46, 42–44. https://doi.org/10.1002/jppr.1280
Evans, E. W. (2017). Conscientious objection: A pharmacist’s right or professional
negligence? American Journal of Health-System Pharmacy, 64(2), 139–141.
https://doi.org/10.2146/ajhp060283
Fink Iii, J. L. (2016). Legal Duty to Preserve Evidence of a Dispensing Error? Pharmacy
Times, 82(9), 73. Retrieved from http://search.ebscohost.com/login.aspx?
direct=true&db=aph&AN=118663768&site=ehost-live
Fudin, J. (2016). Blowing the whistle: A pharmacist’s vexing experience
unraveled. American Journal of Health-System Pharmacy, 63(22), 2262–2265.
https://doi.org/10.2146/ajhp060144
Krajnović, D., & Jocić, D. (2017). Experience and Attitudes Toward Informed Consent in
Pharmacy Practice Research: Do Pharmacists Care? Science & Engineering
Ethics, 23(6), 1529–1539. https://doi.org/10.1007/s11948-016-9853-3

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Singer, A., & Fernandez, R. D. (2015). The effect of electronic medical record system use on
communication between pharmacists and prescribers. BMC Family Practice, 16, 1–6.
https://doi.org/10.1186/s12875-015-0378-7
Starr, D. S. (2015). Potential side effects of medication unexplained. Cortlandt Forum, 17(7),
86–89. Retrieved from http://search.ebscohost.com/login.aspx?
direct=true&db=aph&AN=13873267&site=ehost-live
Webb, J. (2015). To prevent dispensing errors, malpractice lawsuits, pharmacies must
enforce systematic vigilance. Drug Topics, 159(3), 28–30. Retrieved from
http://search.ebscohost.com/login.aspx?
direct=true&db=buh&AN=101775565&site=ehost-live