Medication Safety & Medical Error

Running Head: MEDICATION SAFETY & MEDICAL ERROR
MEDICATION SAFETY & MEDICAL ERROR

MEDICATION SAFETY & MEDICAL ERROR
Introduction
In order to promote clinical excellence, it is impertinent that medical errors are reduced
and medication safety is administered (Choo, Hutchinson & Bucknall, 2010). In the current
scope of discussion a patient's mother narrative has been analyzed related to the safety of health
care. The video is seen on YouTube and was produced for labor-management patient safety
project on medication safety (cirSEIU, 2012). The patient story was related to an actual
breakdown in care resulting in the death of Lewis, a healthy 15-year-old boy.
Patient Story
The narrative was described by the patient’s mother. She recalls the horrifying experience
of what happened to her son at the hospital. Her son Lewis was a healthy 15-year-old boy, who
played soccer, was a top student in Columbia, SC metro area and he also acted in the community
theater. Back at home he was easy-going, very popular amongst his peers, and had a very good
sense of humor.
He was taken to the hospital after a cosmetic condition and he was slightly dehydrated at
that time. After the surgery, he was not producing urine, though his parents reported regarding
the same, there was no doctor visiting him (Gaal, Verstappen & Wensing, 2011). He failed to
urinate after the surgery and it took him two days prior to changing orders amongst the staffs to
increase his fluids to provide adequate dosage. He continued to be in pain after the surgery and
was not able to urinate. Lewis weighed 120 pounds and was provided with an adult dosage of
NSAID ketorolac tromethamine to reduce his pain. At this juncture, Lewis is seen to be given
inappropriate drug without considering for patient safety. His narcotics levels are continuously
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MEDICATION SAFETY & MEDICAL ERROR
increased as he maintains high levels of pain. This was considered to be very dangerous as he
was faced with high fluid deficiency.
After three days of the surgery, Lewis complains regarding severe, unremitting epigastric
pain and no attention was paid to him. The nurses, residents along with other staffs did not act
when Lewis showed increasing signs of instability. Lewis is seen to have dark circles under his
eyes and he is unable to walk . He starts feeling tremendously weak and is still left unattended by
staffs. He feels agonizing pain and has cold sweats. His belly seems to be distended and he has
no bowel sounds. His respiratory rate is very high and is still not attended. His parents
continually request for the attending physician but no one comes to their rescue. Even at this
stage, Lewis is not attended over two days period.
Lewis is unable to sustain his condition and dies. His autopsy reports revealed a giant
duodenal ulcer. It was with 2.8 liters of gastric and blood secretions in the peritoneal cavity, it
was consistent with an NSAID overdose. The primary contributing factor of Lewis decline was
identified to be unfamiliarity with reaction and dosing of the drug and medical contradictions
with side effects. Further, there were no nurses adequately trained, who could challenge the
incorrect orders, change the plans and intervene on a patient (Patel & Balkrishnan, 2010). The
physicians, as well as the nurses, failed to assess, intervene and escalate even in case of the
alarming condition. They could not identify signs of sepsis and shock with Lewis deteriorating
condition. They never called a code in it was necessary. The nurses lacked awareness of the
situation, failed to communicate, or escalate and finally rescue the boy from his condition.
Analysis of care & contextual factors inpatient
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MEDICATION SAFETY & MEDICAL ERROR
Safety in dealing with a patient is based on process and experience. The Significant Event
Audit (SEA) offers the most comprehensive process for evaluating a patient’s condition (McKay,
Bradley, Lough & Bowie, 2009). Evaluating the patient's case using the SEA, a qualitative
evaluation can be constructed. The seven stages of SEA includes;
Awareness and prioritization of the significant event is the first step. In this case, the
nurses nor the clinical staffs made the patient's case a priority through the patient condition was
deteriorating significantly. The staffs and nurses should have prioritized the case and taken an
urgent decision for the patient.
Information gathering. Members need to gather information relevant to the case, to
identify and prioritize the significant event in a confident manner (Bowie et al, 2016). The
nurse’s neither did other clinical staff was able to diagnose the urgency of the patient's severity.
The nurses did not prioritize the event an treated the patient at par with general patients even in
his deteriorating condition.
The facilitated team-based meeting as few people has access to data and information.
Practicing a computer-based system for logging significant cases, which is available to staff and
conducting team-based meeting (Gillam & Siriwardena, 2013). There was no mention of
computer records for the case or any case being mentioned in the video. This implies that the
patient case was not adequately provided and nurses were not aware of the patient's health
condition.
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