Case Study Review: Human Patient Safety and Medical Error Analysis

This case study examines a medical error scenario where a patient received the wrong medication during cancer therapy. The analysis employs the Human Factors Analysis Classification System (HFACS) framework to dissect the root causes of the error, encompassing professional misconduct, lack of standard operating procedures, and various error types such as skill-based, decision-based, perceptual, and exceptional errors. The study highlights how factors like heavy workloads, poor communication, and inadequate adherence to protocols contributed to the medication error. It emphasizes the importance of clear communication, accurate drug labeling, and patient involvement in their care to prevent such incidents. Furthermore, the analysis underscores the need for strict adherence to standard operating procedures, effective team working, and organizational influences to enhance patient safety and minimize medical errors. The case study concludes by advocating for the utilization of the HFACS framework as a risk management tool to improve patient safety practices in healthcare settings.

Running Header; Case Study Review
Student name
Task
Human Patient Safety
Video review on medical error
University

H u m a n P a t i e n t S a f e t y
Case study review on Human Patient Safety
Introduction
The use of HFACS (Human Factors Analysis Classification system) framework in
health sector is a critical tool in assessment of root cause analysis of human practice gaps.
The tool entails causal categories which exonerate four levels of error causation and various
nanocodes aligned to it. In assessing medical practice, these tools will be utilised in reviewing
the video on Learning From Error. The framework herein details how various aspects of the
tier interplay and impact on human factors and its effects on patient safety, (Diller et al.
2014).
In health care practice the prevalence of medical errors has recorded high numbers with
1 in every 10 patients being taken in for medication for suffering from forms of medical
malpractice. In some cases it has led to death of patients and major disability cases in health
care delivery, (Donaldson et al. 2000).
In this analysis we shall focus on a case study in which a patient destined for cancer
therapy medication was administered wrong injection medication which could lead to serious
medical case for the patient.
Factors that contributed to error
Professional misconduct
Factors that may have led to the pharmacist breaking the protocol are many and varied.
This could have been attributed to heavy work schedule and tough working conditions which
don’t offer an opportunity for the questioning of the doctor in charge. The doctor was
administering chemotherapy medication for patient Jean Hughes. The doctor based on his
specialization should not have allowed administering the medication since he was an
expertise in that field. However despite this the nurse allowed him to operate in the ward
while the pharmacist gave him the medication irrespective of questioning its usage.
Lack of basic standard operating procedures
In most health care settings, there have been set and laid down procedures which offer
strict guidance’s on the use of chemotherapy drugs. Such procedures have incorporated
avenues such as prohibition of mixed storage of drugs with other medications and its
therapeutic nature clearly outlined. These rules and regulations are referred to as standard
operating procedures which allow treatments to be given in a specialised rooms or bays. The
illustration of the case study showed that the basic guidelines were not followed in offering
medication process to patient Jane. The mix up of the two medications led to breach of the set
protocol and it could to severe medical complications.
2

H u m a n P a t i e n t S a f e t y
Acts that led to the medical error
Skill based error
The case study illustrated how Dr. Campbell mistakenly administered wrong
medication on the patient. The medical doctor finds himself in a difficult position having an
open spinal syringe for and on the other hand has lethal drug which he later injected to the
patient completing the cycle of the medical error act. If critical care process had been taken,
these acts could have been prevented.
Decision based error
The drug which the patient was injected could have been avoided if a protocol had been
adhered to. The injection of the drug was lethal to the patient and could have significant
harm. Failure for the doctor and the nurse to confirm accurately the medication process led to
poor decision making process.
Further Dr. Campbell being not qualified to perform such kind of care to the patient,
should not have been allowed to perform chemotherapy session to the patient. Despite the
nurse knowledge on the doctor, she blatantly allowed the doctor to perform the care leading
to acts of medical error.
Perceptual error
The actions of care portrayed in the case study shows how generalized care and unsafe
systems can lead to medical errors. The error made based on the prescription of patient Jane
Hughes and mix up of drugs led to the medical error commission. The full prescription is
signed with ignorance of any standard operating procedures to be followed by the medical
practitioner in administering the drug to the patient.
Exceptional error
Exceptional errors have been performed in this medical performance in the manner that
the set procedures have been misunderstood. This can be traced to poor organizational
structure, lack of clear communication poor coordination and professional negligence, could
have led to lack of adherence, (Diller et al. 2014).
The medical practitioner handling the patient blatantly violated the standard procedures
and safety measures with regard to the pharmacist allowing both drugs to be taken without
prior justification on the usage.
Precondition for the Unsafe acts
Skilled based error and Decision based error
3

H u m a n P a t i e n t S a f e t y
The case study illustrate a series of errors based on human factor which have led to the
patient being injected wrong medication coupled with blatantly wrong medical procedures of
drug administration by the health care staff. The human error performed by Dr. Campbell
shows how lack of clear communication and following right medical procedures can
endanger the life of patients.
Perceptual error and Exceptional error
The root cause analysis shows that the medical staff misinterpreted patient information
leading to misdiagnosis. This illustrates acts of medical malpractice and not following due
diligence and levels of incompetency. The staff ignored the set up operating procedures if
they were there in the health care setting. The health care team suffers lack of well
coordinated communication which led to the medical misdiagnosis.
Supervision Role
Skilled based error and Decision based error
Standard operating procedures and guidelines can be a great protection against medical
errors. The key focus of medical practitioners is to provide safe care process. The adherence
of the operating procedures is geared towards ensuring right process are undertaken. The role
of such procedures is to enable each and every team member to focus on their roles and
perform their duties and functions. Thus, the need for strict adherence of this operating
protocols to minimise medical errors occurrence.
Perceptual error and Exceptional error
Hospitals management need to be at the forefront in pushing for leadership in adoption
of standard operating procedures and operational zing them so as to improve service
deliveries and minimise medical errors. Ethical precedence needs to be in-calculated among
the health care staff so as to ensure that each and every one knows their roles effectively
(Diller et al. 2014).
In the case study, it is clear that nobody had clear overview of professional level of
practice which Dr. Campbell had. The nurse and the pharmacist on the other assumed that the
doctor was well equipped having being seconded by Dr. Livington to step in on his behalf at
the ward to check on the patient
Organizational influences
Skilled based error and Decision based error
In most health care settings worldwide there are strict frameworks in place regulating
chemotherapy medication. The measures which have been set up include safe storage
practices and avoidance of gross contamination with other drugs. Regulations have been set
4

H u m a n P a t i e n t S a f e t y
and are being practiced in order to safeguard its usage. Strengthening of such systems is
pivotal in prevention care. There is need for critical care control points to be formed so as to
identify any lapses which might arise in the medical practice.
Perceptual error and Exceptional error
Frameworks and regulations are safe practices which offer a guideline on usage of
drugs and medical practice in general. Organizations such as the American College of
surgeons and WHO have been pushing for safe medical practices which minimises medical
drug error administration.
The case study review, illustrated a complete blatant disregard of the basic standard
procedures and guidelines for both medical practice and drug administration. Several human
factors could be attributed to such occurrence. The pharmacist could have flouted the basic
rules for reason such as work pressure and work practices which don’t offer an opportunity to
gauge the doctor in charge for its usage before dispensing.
Prevention of the Acts
Skilled base error
Clear communication and effective team working between different health care workers
in various professional backgrounds is key towards safe care practices for patients, (Chasin &
Loeb, 2011). Health care setting need to be specialized and have a clear communication base
from different fields is key towards ensuring clarity of responsibilities among the different
health care staffs. Research has indicated that poor communication from the medical team
often leads adverse effects on patients.
Decision based error
Accurate labelling and administration of drugs is key towards alleviating such error as
seen in the case study review. Research has indicated that upto 30% of the medical errors are
occasioned with wrong drug medication, (Medica, 2008). Adoption of drug administration
regulation is key in preventing such mix ups and pharmacists need to be trained on clear
protocol of administering drugs.
Exceptional error
In dispensing drugs there is need for proper checking of the contents by the persons in
charge with regard to patient records as indicated in patients file. Information for high risk
treatments such as chemotherapy medication need to be provided by trained personnel. There
is need for drug checking mechanism is key in ensuring that eminent drug errors medication
are avoided such as those which are similar.
5

H u m a n P a t i e n t S a f e t y
Perceptual error
There is need for medical staff to involve patients in their own medical care, (Aas,
2008). In the case study patient Jane was no longer valued as a patient who would have
provided valuable information regarding her care. this perhaps could have prevented the
occurrence of such error from the patient. The need for involving the patient on care provided
is key towards having wholesome medical care. Thus enabling patient cantered care approach
is key towards removing barriers to perceptual error among medical practitioners.
Conclusion
Thus the usage of Human Factors Analysis Classification System framework (HFACS)
in medical practice is essential in assessment of medical errors. This framework has clearly
displayed how the medical protocols were undertaken in the case study. Using it as a tool for
risk management is key in reducing medical errors.
References
Aas, A. L. (2008, January). The human factors assessment and classification system
(HFACS) for the oil & gas industry. In International Petroleum Technology
Conference. International Petroleum Technology Conference.
Chassin, M. R., & Loeb, J. M. (2011). The ongoing quality improvement journey: next stop,
high reliability. Health Affairs, 30(4), 559-568.
Diller, T., Helmrich, G., Dunning, S., Cox, S., Buchanan, A., & Shappell, S. (2014). The
human factors analysis classification system (HFACS) applied to health care. American
Journal of Medical Quality, 29(3), 181-190.
Donaldson, M. S., Corrigan, J. M., & Kohn, L. T. (Eds.). (2000). To err is human: building a
safer health system (Vol. 6). National Academies Press.
Medica, L. A. (2008). Comprar Why Hospitals Should Fly: The Ultimate Flight Plan To
Patient Safety And Quality Care|| 9780974386065| Varios. Why Hospitals Should Fly:
The Ultimate Flight Plan To Patient Safety And Quality Care-9780974386065-
4988000000, 00.
6