Coronial Clinical Case Study on Medication Error and Nursing Ethics

Running head: CORONIAL CLINICAL CASE STUDY
Coronial Clinical Case Summary
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Author Note

1CORONIAL CLINICAL CASE STUDY
Medication errors are some of the preventable mistakes, which are a resultant of
erroneous administration of pharmaceuticals, which can jeopardize patient safety and even cause
fatality in extreme cases. A report provided by the IOS Press in Amsterdam, showed that nearly
251,000 people lose their lives as result of medication error annually in the United States
(Anderson Abrahamson & Na 2017). The report aims to describe a Coronial clinical
investigative case study of a patient named Mrs. T who expired due to clinical error governed by
the respondent nurse. The critical analysis of the nursing guide is to be described in the following
discussion will emphasize on the medication malpractice, ethical issues and legislative issue that
could arise in such cases.
The patient was under psychiatric review due to major depressive disorder and has a
history of depression, cholesystectomy, ischemic heart diseases and reoccurring urinary tract
infection. The patient was admitted to the hospital with dehydrated condition, which
subsequently deteriorated and was under constant monitoring and required assistance for
changing and other smaller activities. The patient was prepared for a transfer to a psychiatric
hospital. The associate unit manager, here and now referred to as nurse A had instructed the
registered nurse, here and now will be referred to as Nurse B to administer the patients
medications prior to her discharge to avoid re-hospitalization (Hasan et al., 2010). The nurse B
misread the medication chart and administered Nitrazepam or Mogadon 15mg that is an
antidepressant instead of mirtazapine or Avanza 15mg that is a potent sedative.
The National Safety and Quality Health Service (NSQHS) Standard in Australia has a set
of guideline for promotion of safety in health care, whose Standard 4 describes the medication
safety guidelines, “Clinical leaders and senior managers of a health service organisation
implement systems to reduce the occurrence of medication incidents, and improve the safety and

2CORONIAL CLINICAL CASE STUDY
quality of medicine use. Clinicians and other members of the workforce use the systems to safely
manage medicines” (Standard, Q. I. G., 2012). In light of the current case study provided, the
incident could have been avoided by completing independent double-checking by both nurse A
and nurse B, which was not seen in this case. This form of medication error is very common in
the healthcare industry (Jones 2014). The nurse A, showed lack of supervision, as she was
responsible to make sure that the order she provided was properly followed. The nurse B misread
the medication chart, which was a sign of carelessness on her behalf.
Double-checking is a widely accepted standard of clinical practice, which is very useful
to prevent errors in healthcare service (Hewitt, Chreim & Forster, 2016). The nurse B in this case
could have doubled checked the medication chart and stopped herself from administering a
sedative in place of an anti-depressant. The nurse also could have independently double checked
the medication procedure and prevented the medication error. This is a kind of supervision error
in the case for the nurse A, who is the senior authority in this case (Reid‐Searl, Moxham &
Happell, 2010). Since the above suggestions were not followed, it lead to the development of
loss of consciousness, hospital acquired pathogenesis, gastric aspiration and ultimately septic
shock, which gave rise to her death.
There are many ethical considerations to be undertaken in nursing practices, one of them
medication administration principles. It is important to recognize the patient’s problems and then
administer medication with respect to his or her need (Mitty et al., 2010). Assessment and
understanding of the kind of drug being used is also another consideration in the medication
ethics, which helps avoiding drug based adverse reaction. It is important to focus decision based
on the route in which the drug will be administered which is focused based on the patient’s needs
and state of health. Time of medication is another aspect, which needs to be considered when it