Medical System Errors: A Case Study Analysis of Patient Zoya

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Case Study Report
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Case Study Report
Introduction
Medical system errors are a common phenomenon in current medical practice. They are
described by an act of clinical omission which often results in patient harm or even death.
[1]This case study analyses Patient Zona, being offered medical assistance for an ear
infection. This report gives an overview of description, medical practices and issues under
focus and offering a conclusive recommendation based on the issues discussed based on
computerized medical practice.
Case Description
Patent Zoya is a 36-year-old factory worker living in the suburbs of Sydney Australia,
having a medical history of allergic reactions ranging from painkillers advancing to
antibiotics. Zoya, has had an ear problem which caused inflammation. Due to this she
booked an appointment at Get Well Clinic and was given an appointment. She was seen by
Dr. Stanley an experienced general practitioner.
During the appointment, Zoya, presented with severe pain and severe earache on her
right ear and having persistent pain. Dr. Stanley observed the patient and diagnosed otitis
externa. Upon this confirmation, Dr. Stanley, as usual practice is to offer patient antibiotic
ointments and topical antibiotic or oral medications. Due to the case presented by Zoya, the
Doctor prescribed orals antibiotic Cefaclor.
The Get Well Clinic utilizes electronic database system to document patient
information, thus meaning Zoya records were well intact in the system since the facility has
been her preferred medical place. Normally Dr. Stanley is not used to using the
computerized medical system. His usual practice is to check patient notes and ask few
questions regarding allergies, medication history, and drug allergies. Dr. Zoya, prescribed
the medication of Ceclor to Zoya, without proper consultation with the system to check
previous medical patient history. Later on, Dr. Stanley noted the patient consultation and
entered the details into the system, however, he did not undertake any previous drug-related
reviews.
Patient Zoya upon leaving the hospital went to the pharmacy, where he was given the
medication prescription offered by the GP practitioner. The pharmacist offered the patient
the medication without prior consultation of any adverse reactions and allergies. The patient
returned home and took the drugs immediately; unfortunately, the patient convulsed and lost
conscious. Emergency care was sought and the patient rushed to the emergency care. Patient
Zoya had developed full-blown cardiac arrest, he was placed in intensive care unit and

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Case Study Report
offered life support machine, her health deteriorated, with no cerebral perfusion occurrence
in the brain. Upon consultations, patient Zoya had developed brain death and all
medications were exhibited and pronounced death. This occurred due to an allergic reaction
of antibiotics which Patient Zoya. Based on her medical history, she had experienced an
allergic reaction to penicillin, cephalexin, and sulfur based antibiotics.
Discussion
Case discussion
The clinical decision by Dr. Stanley was not certified in this case. Oral antibiotics are
not recommended treatment options for otitis externa. [1] Choice between topical and
systematic treatment should have been offered to the patient. It is evident that the Doctor
did not check patient medication as per recommendations for Australian s standards for
general practice. [2]
Further systematic issues at the clinic data information system where the hospital data
quality management proves to be an issue. The medical information’s of the patient were
incomplete. The clinic has no record of the medial allergies which the patient has. Further
allergies presented in the medical record indicate the brand names of drugs instead of the
original drugs of the patient, further patient discharge record were not available at her health
care clinics.
The hybrid system adopted by the doctor, proved to offer misleading guidance on the
patient status, the risks portrayed by this system is that it does not offer an opportunity for
analyzing the case study of the patient. Further, the hospital decision support system proved
to be a challenging for functioning. The clinical support system has the powers t offer
support to detecting medical allergies for the patients. However, the doctor's role could not
be detected by the system at the clinic due to lack of hard stop features and configuration
feature for offering decision support mechanisms for prescription of alerts.
Further at the pharmacy, the pharmacist could have inquired on the allergies which the
patient could have presented. Australian pharmacy standard for pharmaceutical dispensing,
patient allergies ought to inform any dispensing of drugs. In this way, a lot of patient
allergies could have been noted and prevented.
Case analysis
System redundancy
Many systems have focused on improving quality management and behavior provider
behavior, however changing systems is far much more critical than behavior change

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attitudes. Computer systems are tools which have to be in calculated with responsibility in
order to ensure that tools are well operationalized. The system utilized by the Get Well
Clinic lacked redundancy systems and alert systems to offer human support. The system had
enough spot-check and key information, however, they were not reliable in detecting and
offering a visible guideline to the GP. System functions offer redundancy in two forms that
are active and passive forms. An analysis by Ong & Coiera [3] assessed redundant
processes, shows that redundancies offer a safeguard to processes, however they are
ineffective in providing this prevention, the system in at getting Well Clinic ought to have
detected patient allergies and provide an alert system which doesn't offer access for further
medication process upon confirmation.
The effectiveness of clinical handover
According to Australian medication association, safe transfer often requires effective
handover between hospital professionals. Critical aims of handover are to achieve effective
communication and offering high-quality information at any time during patient
responsibility transfer. Zoya’s case ought to have been delivered through effective handover
and ensuring that family doctor noted all the critical patient information; this could have
facilitated effective treatment for the patient. Zoya medical information regarding allergic
reactions as observed was not effectively documented and shared between the Family GP,
Get Well Clinic and the local hospital.
Continuity of care
Continuity of care has proven to offer positive healthcare outcomes in primary health
care settings. [4] Effective continuity of care is linked to interpersonal relationships and
better sharing of data and knowledge between physician and patients. [5] Patients having
high continuity of care ratings have been noted to experience less emergency visits and
admissions to hospitals which aids better primary care process. Effects of continuity of care
on utilization of health care system show the high utilization of care.
Continuity of care is key in achieving better outcomes, building a comprehensive
health system of patient-centered care offers proactive management process for patients. [6].
Continuity of care systems offers reinforcement to primary care clinics, which are design to
link patient proffered physician. The characteristics of these systems are to offer an
effective process of delivery most care through provider networks. A comprehensive health
care system into-operating continuity of care offers proactive management and achieves
better patient outcomes.