University Ethics and Law: Medication Error Case Study Analysis

This assignment presents a detailed analysis of a medication error case involving a registered nurse, Ryu Sakamoto, who administered an incorrect dosage of blood-thinning medication to a patient, Kev Forbes. The case explores the ethical and legal ramifications of the error, including breaches of the ICN code of ethics, violations of ethical principles such as autonomy and beneficence, and potential legal issues related to negligence and documentation. The assignment examines the nurse's actions, the patient's rights, and the importance of effective communication and patient-centered care. It also considers the legal issues of consent and professional boundaries. The solution applies the Nursing Codes of Conduct by the Nursing and Midwifery Board of Australia, focusing on decision-making, adverse events, effective communication, and professional behavior. The project concludes with an assessment of the outcomes and recommendations for preventing future errors, emphasizing the need for collaboration among healthcare professionals and open communication with patients and their families.

Running head: ETHICS AND LAW
ETHICS AND LAW
Name of the Student:
Name of the University:
Author Note:

1
ETHICS AND LAW
Identification of the issue
The issue that is presented here which is portrayed through the given situation deals
with the medication errors. The registered nurse, Ryu Sakamoto has been working in a
hospital in Brisbane and was given the duty in the general ward. In the same hospital the
patient Kev Forbes was admitted after he had experienced a fall at his home. The patient
suffered from a small head wound after the fall. As the patient had a past history of
mechanical heart valve surgery therefore had been prescribed a blood-thinning medication
after his surgery which he needs to take daily. While the ward was quite crowded on a day
and most of the nurses were called in for the other patients, and the RN responsible for the
patient was fatigued after a long shift. In spite of this, RN Sakamoto had to rush to get the
medication rounds and he did not want to wait till another nurse becomes free therefore he
himself administered medication to the patient, Kev. In doing so all of this so hastily, he
forgot to cross-check the medications by another RN. He failed to double check the dosage
and by an accident administered the patient with a much higher dose in comparison to the one
that had been prescribed to Kev originally.
This was the major issue here, after the medication had been administered to the
patient, he soon started feeling nauseated and started vomiting. While the treatment team
started investigating the situation of the patient, it was discovered that a medication error has
occurred. There was also an issue regarding delivering news to the patient’s wife. The patient
did not want to reveal to his wife his present health condition whereas the RN thought it
would be right to inform her about it.
Evaluation of the issue
ICN code of ethics:
The elements of the code are as follows:

2
ETHICS AND LAW
1. Nurses and people
2. Nurses and practices
3. Nurses and the profession
4. Nurses and the co-workers (Epstein& Turner, 2015).
The elements of the code should be applied by the nurses during their practise. In
terms of the given situation here, the nurses should have followed the following aspects
of the code which being:
“The nurse’s primary professional responsibility is to people requiring nursing care”
– Considering this, it can be stated that the RN responsible for the patient here Kev, failed
to show a professional responsibility. While the patient did not wanted his health
condition to be disclosed to his wife, the RN also had a dilemma which should not have
been present.
”The nurse maintains a standard of personal health such that the ability to provide
care is not compromised.”- The RN by making a medication error failed to maintain the
integrity of the patient care.
“The nurse is active in developing and sustaining a core of professional values.”- The
RN although was fatigued after a long day, should not had compromised the well-being
of her patient. This portrays that she could not sustain her professional values.
“The nurse sustains a collaborative and respectful relationship with co-workers in
nursing and other fields”- As evident from the given case, the RN did not share a
collaborative relationship with the other nurses since there was a clear misunderstanding
while attending the patient which ultimately caused the medication error (Zahedi et al.,
2013).
Ethical principles

3
ETHICS AND LAW
The key ethical principles in nursing include:
Autonomy: Respecting the right of individual in terms of self-determination.
Beneficence: This refers to the duty to do good to others and to maintain a stability between
the harms and the benefits. Hence, all nurses have the moral obligation of displaying
kindness, mercy and charity towards their clients and service users, with the connotation of
providing benefits to the latter. In other words, beneficence lays the foundation for the moral
imperative of doing good.
Non-maleficience: It is the commitment of not doing or causing harm to others.
Justice: It is the unbiased distribution of the potential assistances along with the tasks, in
order to determine the direction in which the patients should be cared for.
Veracity: It is the compulsion to tell the truth
Fidelity: It is the responsibility to do what one had assured (Parahoo, 2014).
Legal issues –
Is Kev allowed to give consent for letting the RN inform his wife about his present
health condition?
Is the RN liable for any breach of professional of ethics as a nurse?
Is the nurse obliged for any proceedings of further inquiry related to the misconduct or
medication error?
The legal issues which are related to the situation present here is mainly of negligence. The
RN failed to establish the standard of care.

4
ETHICS AND LAW
Another legal issue that rose was of documentation. In spite of the fact that the medication
records were maintained, the RN failed to cross check the documents before administering
the medicine (Griffith& Tengnah, 2017).
Action
The principle 2 that focuses on delivering a person-centred, and evidence-based care for the
wellbeing and health of the patients is vital in this regard.
 2.2 Decision-making
Making essential decisions about healthcare often seems overwhelming to the health care
professionals due to the range of issues that they encounter, in relation to their subjects. The
RN Walsh should adopt a person centred approach for effectively managing the concerns of
Kev regarding his wife Bernice, and her probable anxiety on knowing about the former’s
health condition (NMBA, 2018). The RN should provide all possible support to Kev in a
manner that are in complete alignment with his preferences and values.
 2.4 Adverse events and open disclosure
Owing to the fact that Kev suffered due to the adverse drug event, for which RN Sakamoto
was held directly responsible, the RNs must adopt an honest and direct approach, while
communicating with him and his family members, on what exactly had happened. RN
Sakamoto must take all possible efforts for identifying her drawbacks and the circumstances
that led to the overdose of drug administration. Furthermore, this should be followed by
submission of an appropriate explanation and apology by RN Sakamoto to Kev and the
hospital administration(NMBA, 2018). Although RN Walsh is in charge of the home
arrangements of Kev, RN Sakamoto should also act as an active listener and acknowledge all
forms of distress that Kev has experienced due to the adverse event.

5
ETHICS AND LAW
The principle 3 also holds relevance in this case since it emphasises on establishment of
respectful relationship and an effective cultural practice.
 3.3 Effective communication
Owing to the strong positive association between the communication skills of a health care
professional and the capacity of a service user to abide by the medical recommendations, the
RNs must communicate in an appropriate manner with Kev. They must gain an insight into
the health literacy of the patient, and make possible arrangements for meeting the specific
cultural, communication and linguistic needs of Kev. They should also adopt a non-
judgmental approach while communicating with Kev(NMBA, 2018).
The principle 4 of professional behaviour also holds relevance in this case.
 4.1 Professional boundaries
Both the RNs should recognise any kind of power imbalance and should manage the
expectations of Kev by avoiding sources of possible conflicts and complications. RN Walsh
should also take into account that over-involvement of any kind might create a detrimental
impact on delivery of healthcare services(NMBA, 2018).
Implementation
For the implementation of the above actions, RN Walsh must perform the following duties in
accordance to the Nursing Codes of Conduct by the Nursing and Midwifery Board of
Australia (Nursing and Midwifery Board of Australia, 2018):
 In accordance to Principle of 2.2, which informs about Decision Making, RN Walsh
must consider that decisions pertaining to treatment and healthcare is a collective
responsibility which must be shared not just across nurses and associated healthcare
professionals but must also involve participation of the patient as well as associated

6
ETHICS AND LAW
family members in the decision-making process. Hence, in accordance to this Code of
Nursing Conduct, RN Walsh must adopt a patient centred and family centred
approach to treatment wherein he must inform Kev’s wife considering the recent
incidents during his hospital stay and the proposed extension of residing in the
hospital for further observation before discharge.
 In accordance to the Principle 2.4 of Nursing Code of Conduct which emphasises on
Adverse events and Open Disclosure, RN Walsh as well as RN Sakamoto, must also
consider the occurrence of medication error for Kev. Hence, as stated in this principle,
RN Walsh and RN Sakamoto, must reflect on the details of the adverse incident and
inform the same to Kev and his wife with honesty and further acknowledge their
feedback or distress considering the issue while further seeking supervision from his
supervisor or employer.
 In accordance to Principle 3.3 outlining Effective Communication, RN Walsh must
consider the importance of transparent communication practices for the purpose of
maintaining healthy nurse-patient relationships. Hence, he must consider that despite
Kev’s disinterest in informing his wife, the registered nurse must engage in effective
communication by taking into account patient’s health literacy levels and hence, must
inform his wife concerning his extended stay in the hospital.
 In accordance to the Nursing Code of Conduct of 4.1 outlining Professional Practice,
RN Walsh must respect his professional nursing relationship with Kev which
necessitates avoidance of personal belief and necessitates recognition of imbalance
between nurses and patients. Hence he must undertake an ethically correct decision
of informing his wife, which is in accordance to his professional duties as a nurse.

7
ETHICS AND LAW
Assess the outcome
The registered nurses appointed for Kev, must evaluate the reasons behind the
incidence of medical error which had occurred, inform and obtain feedback from Kev
concerning his views on the incident and then work actively to prevent this in the future.
RN Walsh must consult RN Sakamoto along with his supervisors and other healthcare
professionals for a final decision to be undertaken considering informing Kev’s wife Bernice
about his hospital stay extension.
References
Epstein, B., & Turner, M. (2015). The nursing code of ethics: Its value, its history. OJIN: The
Online Journal of Issues in Nursing, 20(2), 1-10.
Griffith, R., & Tengnah, C. (2017). Law and professional issues in nursing. Learning
Matters.
Huston, C. J. (2013). Professional issues in nursing: Challenges and opportunities.
Lippincott Williams & Wilkins.
Kangasniemi, M., Vaismoradi, M., Jasper, M., & Turunen, H. (2013). Ethical issues in
patient safety: implications for nursing management. Nursing ethics, 20(8), 904-
916.
Nursing and Midwifery Board of Australia. (2018). Code of conduct for nurses. Retrieved
from http://www.nursingmidwiferyboard.gov.au/documents/default.aspx?
record=WD17%2F23850&dbid=AP&chksum=L8j874hp3DTlC1Sj4klHag%3D
%3D.

8
ETHICS AND LAW
Parahoo, K. (2014). Nursing research: principles, process and issues. Macmillan
International Higher Education.
Zahedi, F., Sanjari, M., Aala, M., Peymani, M., Aramesh, K., Parsapour, A., ... & Dastgerdi,
M. V. (2013). The code of ethics for nurses. Iranian journal of public
health, 42(Supple1), 1.