Healthcare Malpractice and Error Prevention

This assignment involves analyzing a case study of healthcare malpractice that resulted in premature delivery due to improper drug dispensing. The case had significant legal implications and highlighted the need for accountability and understanding among healthcare practitioners. To prevent such errors, various procedures and protocols must be implemented. This analysis will delve into the details of the case, its consequences, and the steps that can be taken to ensure similar mistakes are avoided in the future.

Running head: CRITICAL THINKING: CASE STUDY – MEDICAL MALPRACTICE REPORT 1
Critical Thinking: Case Study – Medical Malpractice Report
Student Name
Institution

CRITICAL THINKING: CASE STUDY – MEDICAL MALPRACTICE REPORT 2
Table of Contents
1. Introduction.........................................................................................................................................2
2. The case...............................................................................................................................................2
2.1 Ethical principles................................................................................................................................3
2.2 The legal implications........................................................................................................................4
2.3 How to manage the case...................................................................................................................6
2.4 Recommended Prevention of the case..............................................................................................6
2.5 Recommendation Implementation procedures.................................................................................7
3. Conclusion...........................................................................................................................................8
Reference..................................................................................................................................................10

CRITICAL THINKING: CASE STUDY – MEDICAL MALPRACTICE REPORT 3
1. Introduction
Medical malpractice in one of the serious health care challenges affecting many patients
throughout Saudi Arabia. One of the medical malpractices involves prescription of wrong drugs
to the patient resulting in medical complications and mortality (Khaliq, 2012). Many healthcare
practitioners do not seek the consent of the patient or provide necessary information concerning
medication to the patient before treatment. Some of the most affected health professionals
include pharmacists and physicists. The subsequent result includes lawsuits due to wrong
medication provided to patients who sometimes develop complications such as premature
delivery, poor patient health and some succumb to death (Hamdan, 2005, pp 42–64). Some
malpractices also involve improper communication between health care professionals or errors
caused by incompetent health care practitioner in the line of duty. Illness and fatigue are also
some other factors contributing to healthcare malpractices. There are ethical standards that
healthcare professionals need to follow when in the line of duty. The ministry of health also
provides various guideline and procedures to use while dispensing drugs to patients in hospitals.
The following critical thinking report provides analysis of the case study and recommendations
prevention of case.
2. The case
The study involved an allegation of pharmacist dispensing wrong drugs to a 23-year-old
female patient that resulted in the premature delivery of 23 weeks fetus. The labor and delivery
nurse, on the other hand, had no idea the implication and usage of Prostin on the patient hence
administered the drug to the patient. In the case, the pharmacist on duty administered Prostin
suppository instead of progesterone suppository to stop the virginal bleeding. Though the

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defending pharmacist claimed to be ill at the time of malpractice, the pharmacist was also not
familiar with the progesterone suppository administered. The end result was impairment of the
fetus and subsequent premature delivery of 23 weeks old fetus. Furthermore, the pharmacist on
duty complained of fatigue and need relieve from another pharmacist (Health Service Providers
Organization, 2013). The fetus was severely impaired and had to be transferred to another
hospital for intensive care. Therefore, the pharmacist, labor and delivery nurse and hospital are
held responsible for the medical malpractice.
2.1 Ethical principles
The ethical standards offer the perspective that outlines the relationship between
pharmacist, patient and the organization. Firstly, the pharmacist did not observe the ethical
standards and codes before dispensing the drug to the patient as evidenced by improper
administration of Prostin suppository instead of Progesterone suppository that she could have
used. The ethical codes of practice clearly outline the ethical standards that are expected from a
pharmacist especially when dispensing life-saving medication to patient or client. It was
unethical for the pharmacist to dispense the drug to a patient without proper knowledge of the
action and implications of the drugs itself. In addition, the pharmacist did not properly
understand policies and ethical standards guiding the use of drugs and medication. This is
evident in her failure to distinguish between Prostin suppository and progesterone suppository
(Buchanan, 2006, pp 290–304).
Secondly, from the patient’s perspective, the patient is entitled to satisfactory medical
care with minimal risk. It is therefore not ethical to receive improper medication couple with
high risk as evidenced in the case study. Ethical codes also dictate that the consent of the patient

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needs to be considered before administering medication (Saudi Food & Drug Authority, 2011).
As in the case, the pharmacist did not seek the consent of the patient as the norm requires.
Moreover, the ethical standards indicate that pharmacist should present all the information to the
patient concerning drugs before dispensing to patient. The patient needs to have given consent
due to information on drugs given without pressure from the pharmacist.
The hospital also had ethical responsibility to bear given that the pharmacist complained
that she was ill and fatigue due to overtime work. The hospital ought to have used its ethical and
standards of practice to streamline communication between employees and patients. The
pharmacist needs not to have overworked despite complaints from the employee of illness. The
relieving pharmacist on duty needs to have come in time to take over duty at the hospital to avoid
complication as witnessed. Furthermore, the use of technology in confirmation of drugs the
computer gave a different drug name instead of the original drug. This is against the ethical and
standards of practice that is expected from a life-saving organization. The labor and delivery
nurse though not aware of the drug error is also responsible for malpractice since as practitioner
she needs to have understood reasons administering the drug (Aldossary, While & Barriball,
2008, pp 125–8).
2.2 The legal implications
The case presents a critical legal implication that needs serious examination since the
pharmacist did not apply pharmacy policies and was negligence. Firstly, patient or client has a
right that dictates the manner in which the patient is attended to and ensures patient satisfaction.
It is important to note that in the case the patient’s bill of right was not respected. According to
patient's bill of right that govern the pharmaceutical relationship between patient and pharmacist,

CRITICAL THINKING: CASE STUDY – MEDICAL MALPRACTICE REPORT 6
the patient has right to satisfactory pharmaceutical care according to professional standards. In
addition, patients have right to all the information regarding the medication or drugs dispensed to
that patient. Secondly, the hospital and the healthcare practitioner involved are responsible for
the malpractice witnessed in the case. The pharmaceutical and medical laws outline the expected
standard of practice and bridge of these codes of practice come in hand with legal implications.
Moreover, there are various regulations that help regulate the healthcare practice of various
healthcare professionals. This was not followed in the medical malpractice case and all parties
involved need to face the legal action (Yousuf, Akerele & Al-Mazrou, 2002). The labor and
delivery nurse, for instance, had no idea on the usage and implication of the wrong drug she
administered to the patient.
Some laws that were involved include pharmacy patient’s bill of right, professional code
of conduct and ethics, and Law of Pharmaceutical Establishments and Preparations. Firstly,
pharmacist patient bill of right was not considered in the case since various aspects of the patient
right such as the right to information, quality care and satisfactory standard of care were not
considered. Secondly, professional code of conduct and ethics were not followed when the
pharmacist carelessly dispense drugs despite the error of name in pharmacist computer. The
pharmacist and delivery nurse as healthcare practitioners act in an unethical manner that causes a
high health risk. Thirdly, Law of Pharmaceutical Establishments and Preparations provide
procedures that are followed through from prescription to dispensing of drugs to the patient. In
the case, various guidelines and procedures involved in prescribing to the administering of the
drug were not followed hence the pharmacist and labor nurse was in haste to administer the drug
to a patient (Ministry of Health, 2010). Finally, codes of ethics are also set guidelines that were
involved in the medical malpractice since ethical standards also act as laws for satisfactory

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practice. Healthcare parties involved in the case exhibited limited observance of ethical codes of
practice as laid out in Saudi Arabian ministry of health guidelines.
2.3 How to manage the case
In order to manage the case from the healthcare perspective, the organization and health
practitioners need to take responsibility for the action of the pharmacist. Firstly, the pharmacist
should be held responsible for her action since she did not act as per the ethical code or standards
of practice. Secondly, the hospital as an organization should be held responsible for the action of
the employee since despite complain from the pharmacist of illness; no action was taken to
relieve her of duty. Improper communication between prescribing practitioner, supervising
pharmacist and pharmacist on duty also lead to wrong drugs. To manage the case procedure need
to immediately establish to reduce any miscommunication. Thirdly, the hospital needs to pay for
any damage cost or compensation to the patient and their family (Shehab, 2001, pp 528).
2.4 Recommended Prevention of the case
There are various precautionary measures that should have considered to prevent the
case. Based on the healthcare ethical codes and standards of practice, there are some steps that
could have been done to prevent any future cases of medical malpractice as in the case study.
Firstly, there could have been proper communication between patient and healthcare practitioner
to ensure patients have enough information regarding medication. The standards of medical
health care practice require pharmacist to obtain the consent of client based on information given
to the patient before dispensing drugs to treat patients. Communication between prescribing
practitioner and the pharmacist also need to properly coordinate to ensure proper consultation
(Aspalter, Yasuo & Robin, 2012, p29-30). This could have reduced any misunderstanding of
drugs leading to wrong medications.

CRITICAL THINKING: CASE STUDY – MEDICAL MALPRACTICE REPORT 8
Secondly, health care practitioners could have been properly trained on the risks of
dispensing wrong drugs to the patient. Training should focus on the protocol of entering drug
order into the pharmacist computer without errors such as drug names. This could have
prevented misunderstanding while entering the drug order into the pharmacist computer.
Training would have also bridged the gap between prescribing health care official and
administering nurse. In addition, training could also assist in creating coherent working condition
between various healthcare practitioners that normally assist in the similar situation. For
instance, training can improve working conditions between prescribing practitioner and
pharmacist or between pharmacist and nurse since they both work in similar line.
2.5 Recommendation Implementation procedures
The implementation procedures for the precautionary measures to prevent the case should
follow elaborate guidelines. Firstly, training of practitioners on teamwork health care service is
the primary procedure for ensuring limited errors in future. Teamwork also highlights the
necessity of every player from physicist to nurse within that line of practice (Moynihan &
Cassels, 2005).
Secondly, clear observation of pharmaceutical protocol and procedure when entering
drug order into the pharmacist computer. The primary reason for the error in the case was a
failure to distinguish between Prostin and Progesterone when entering drug order in the
computer. Procedure and protocol followed needs to be clear, precise and without any confusion.
This should also use clear approved sig codes that minimize any error that might be incurred
(Hattingh, Low & Kim, 2013, p27).
Thirdly, linking various related healthcare departments is the number two procedure.
There is a need for proper coordination of healthcare for patients between various healthcare

CRITICAL THINKING: CASE STUDY – MEDICAL MALPRACTICE REPORT 9
practitioners in a related line of duty. For instance, physicians, pharmacist, and nurse need an
elaborate coordinated care with minimal errors. This will ensure before dispensing drugs the
prescribing practitioner is aware of the drug and the administering nurse is also familiar with the
drug (Almalki, Fitzgerald & Clark, 2011, pp 784).
Fourthly, developing a communication channel between healthcare practitioners is
another procedure that will ensure that problems are prevented in future. Good communication
network ensures that any uncertainty is eliminated and clear communication protocol maintained
by ethical standards is put in place. For instance, suppose there was good communication
between prescribing practitioner and pharmacist the drug name error would have been corrected
before being passed down to labor and delivery nurse that had insufficient information on the
drug (Gold & Miner, 2002).
3. Conclusion
In conclusion, following ethical codes and standards of practice are important healthcare
factors that determine the quality of healthcare services. Various healthcare laws require proper
provision of medication to patients without any health risks. In the case study, improper drug
dispense leads to tragic health care complications that resulted in the premature delivery of 23
weeks fetus. Wrong medication shows there is a clear need for understanding and accountability
of practitioner's healthcare actions. This case had legal implications with different laws being
involved. There are also various steps that would have been followed to prevent these errors.
Subsequently, some procedures also need to be implemented to ensure that future errors in
healthcare service provision are minimized.

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Reference
Aldossary, A. While, A. & Barriball, L. (2008). Healthcare and Nursing in Saudi Arabia.
International Nursing Review, (55):125–8.
Almalki, M., Fitzgerald, G. & Clark, M. (2011). Healthcare System in Saudi Arabia: An
Overview. East Mediterranean Health Journal, (17):784–93.
Aspalter, C., Yasuo, U. & Robin, G. (2012). Health Care Systems in Europe and Asia.
Routledge, p29-30
Buchanan, D.R. (2006). Perspective: A new Ethic for Health Promotion - Reflections on a
Philosophy of Health Education for the 21st century. Health Education Behav., (33):290–
304.
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Terminology Report of the 2000 Joint Committee on Health Education and Promotion
Terminology. Journal of School Health, (72):3–7
Hamdan, A. (2005). Women and Education in Saudi Arabia: Challenges and Achievements.
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Hattingh, L., Low, J. S. & Kim, F. (2013). Australian Pharmacy Law and Practice: Elsevier
Health Sciences, p27, 67
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Study with risk management strategies. Chicago, USA: HPSO and CAN. Available at:
http://www.hpso.com/Documents/Risk%20Education/individuals/LegalCaseStudy/RX_SLCSx-
10122-0213_February2013.pdf

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