Mrs. T’s Case: Medical Errors, Ethical Principles, and Significance of Drug Legislation to Nursing

Running head: MRS. T’S CASE 1
Mrs. T’s Case
Name
Institution

MRS. T’S CASE 2
MRS. T’S CASE
Introduction
This study uses the case of Mrs. T, a patient that died as a result of a medication
error committed by nurse A and B. It will show the need for legislation, scheduling and ethical
theories to be upheld in healthcare environment. The discussion is section in three different
topics. In topic one, a discussion of the medical error that led to the death of the patient is
discussed. Topic one presents a discussion on the type of the medical error; how the error
affected the safety of the patient; occurred; a strategy to prevent the occurrence of the error and
how the strategy would prevent the occurrence of the medical error. Topic highlights whether
veracity and non-maleficence ethical principles were violated or upheld in this scenario. In the
third topic, the medicine and poison discussions and their importance to nursing practice is
presented with an inclusion of the Australian Schedule for Medicines and Poisons, specifically,
schedule 2, 3, 4 and 8.
Topic 1: Medical Errors:
Discuss the medication error
The medical error that occurred here was misread and interpretation of the medicines by
nurses A and B. In this case, Nurse A gave Nurse B nitrazepam instead of mirtazapine to
administer to Mrs. T that eventually triggered her eventual death.
How Error Occurred
This happens in that Nurse B never informed Nurse A of the wrong medicine even after
recognizing discrepancy taking an incorrect assumption that it was another name for the same
drug.

MRS. T’S CASE 3
How error affected Mrs. T’s Safety
This led to Mrs. T’s blood pressure recording “low” that initially responded to position
changes but subsequently plunged again. Mrs. T went into a conscious state and lethargy and
became unresponsive, and hypotensive and diagnosed with septic shock and aspiration
pneumonia. This caused her eventual death despite supportive treatment and yet she was
relatively stable before medication error. It was clear that the inadvertent administration of
nitrazepam as a result of sedative effects caused Mrs. T to aspirate gastric contents culminating
in pneumonia, and subsequently, septic shock making her succumb.
Strategy:
One of the strategy that can be used to prevent medication error is “double checking-or
even triple checking-procedures”. With this strategy, another nurse on similar shift or arriving
staff must review each new order to make sure all order of every patient is noted. Then she
ensures that each order is transcribe properly on order of physician and the “medication
administration record (MAR) or treatment administration record (TAR)”. This hospital should
have a chart-flag procedure that outlines charts with novel orders which are to be verified (Pugh,
Pugh & Savulescu, 2017).
How Strategy would have helped:
Double-checking or triple-checking would ensure that the third nurse apart from A and B
check the medication name correctly and would have also been informed by nurse B who had
noticed the supervisory. If this was to be done, nurse B and the third nurse (say C), would have
then taken the matter with nurse A, and inform her of the disparity leading to realization that it
was nitrazepam instead of mirtazapine that nurse A had given. This would have seen the three
nurses get the correct medicine (mirtazapine).