Case Study: Medication Errors, Patient Safety, and NSQHS Standards

This case study examines a medication error involving a patient, Mrs. D, who experienced a cerebrovascular accident due to a lack of proper communication regarding her warfarin medication upon discharge. The analysis identifies factors contributing to the error, including inadequate communication between healthcare professionals and the patient. It emphasizes the importance of adhering to NSQHS Standard 4.11, which focuses on providing patients with comprehensive medication information. The case study further explores the ethical principles of beneficence and non-maleficence in nursing practice, highlighting how these principles were not fully adhered to in Mrs. D's case. Finally, it discusses the significance of federal legislation, particularly the role of the Therapeutic Goods Administration (TGA) in regulating medications in Australia, along with nursing responsibilities related to controlled substances. Desklib offers this and other solved assignments to aid students.

Running head: CASE OF MISSING SAFETY
CASE OF MISSING SAFETY
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Topic 1: Medication Errors
Factors of Medication Related Error
The primary medication error which occurred Mrs. D, was a lack of adequately
mentioning the requirement of warfarin in the discharge education as well as discharge
medication plan of the patient. Considering the associations between aggravation of
cardiovascular symptoms and emergence of thrombus formation resulting in disruption of blood
circulation for cardiac functioning - regulation of coagulation functioning is of utmost
importance (Martinelli et al., 2016). For this reason, adherence to anticoagulant therapy and
warfarin medications is of utmost importance for Mrs. D. However, it can be observed that the
need for warfarin medications was noted only by the allocated physician but not communicated
to the clinical staff. Hence, this lack of communication resulted in a medication error resulting in
lack of disseminating discharge education to the patient on necessary warfarin intake and
avoidance of INR monitoring (Roughead, Semple & Rosenfeld, 2016).
A key factor underlying the occurrence of a medication error is the lack of adequate
communication between health professionals as well as between health professionals and the
patient. Patient care is a composite of contributory efforts from all health professionals hence
prioritizing the administration of a multidisciplinary approach (Murray et al., 2017). A key factor
underlying prevention of medication errors is the execution of a multidisciplinary approach
where information concerning patient’s needs must be relayed across all health professionals.
Hence, it the key contributor of Mrs. D’s medication error is the lack of communication between
the physician and the clinical staff on the need to continue with warfarin medications and INR
screening (Alex et al., 2016). Additionally, communication between health professionals and

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patients, especially during discharge, is of utmost importance since the same enlightens patients
on necessary interventions to adhere to post clinical interventions. It can be observed that Mrs. D
was only communicated on intake of routine pain medications hence resulting in lack of warfarin
intake and her fatal progression towards cerebrovascular accident (O’Riordan, Delaney &
Grimes, 2016).
NSQHS Standard 4 Action
In order to prevent the occurrence of medication error as observed in Mrs. D, the nurse in
care can adhere to the NSQHS Standard of 4.11, which outlines ‘Information for patients’
(NSQHS Standards, 2019). As per this standard of care, health professionals such as nurses and
clinicians must educate and communicate the patients the need to adhere to required medications,
the availability of various medications and the advantages as well as risks associated with each
medication (Ritchie et al., 2018). From the case study, it can be observed that a key contributor
underlying occurrence of medication error is Mrs. D as well as the clinical staff, not being
communicated on the need to adhere to warfarin intake – hence indicating a violation of this
standard. Hence, to prevent the same the nurse must adhere to this care standard by first
implementing Action 4.2 – which includes providing Mrs. D a patient centered discharge
containing a list of all required medications as per her clinical condition (like warfarin) as well as
a section on available health services with whom she may discuss her medications (Gilbert et al.,
2017). This standard will also require the nurse to adhere to Action 4.13 which will include
usage of a multidisciplinary approach and collaboratively communicating with Mrs. D’s clinical
staff and physician on the need to have access and comply with evidence-based, patient centered
medication information unique to Mrs. D (Trevena et al., 2017). It will also include Action 2.4
requiring obtaining Mrs. D’s consent on intake of her current plan of pain medication as well as

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evaluation of medicine information which would monitor the presence of adequate
documentation of Mrs. D’s medications at all organizational and multidisciplinary professional
levels (NSQHS Standards, 2019).
Topic 2: Ethical Principles
Beneficence
The nursing ethical principle of beneficence outlines that nurses must seek to deliver care
and quality practice for the purpose of ensuring good or benefit to the patient. Hence to ensure
that the same, the nursing formulation of priorities of care and treatment must ensure that the
benefits or possibilities of achieving positive health outcomes in the patient are provided to the
maximum potential so that no form of harm of conductance of nursing maltreatment befalls in
the patient (Pope, Hough & Chase, 2016).
Non-maleficence
For the purpose of ensuring quality nursing practice and ethical compliance, the nurse
must engage in the ethical practice of non-maleficence. The practice of non-maleficence, implies
that the nurse must ensure deliverance of appropriate care and treatment practices which will
inflict no harm or the least possible harm to the patient, considering that every clinical action
exerts its own set of benefits and shortcomings (Ong-Flaherty et al., 2016).
Application
Hence, in terms of the case study of Mrs. D, to apply the ethical principles beneficence,
the nurse in care should have ensure that the ongoing care as well as the discharge plan and
education provided to the patient is directed for the benefit of Mrs. D, so that she recovers from

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her cardiovascular and embolic conditions soon for hastened fulfilment of positive health
outcomes (Manda-Taylor, Mndolo & Baker, 2017). Hence considering the same, in the case
study of Mrs. D, along with the usage of beneficence, the nurse must also engage in nursing
ethical practice of non-maleficence. This can be applied by the nurse as well as clinician in care
by administering treatment and post discharge interventions, which will possibly induce least
possibility of aggravation of Mrs. D’s cardiovascular conditions and ensure recovery, out of a
range of possible alternatives (Aliyu et al., 2015).
However, taking insights from the case study, it can be observed that the these ethical
practices were not fully adhered to by the nurse in care or by the allocated clinical staff, at
present, the adherence to beneficence can be observed in the treating physician as evident in the
prescription of Mrs. D’s warfarin – which was the best possible and probably the most beneficial
treatment considering her embolism. However, in criticism, it must be noted that the benefit to
the patient is the responsibility of every health professional of the clinical team allocated and
hence, a hindrance in beneficence was observed in the avoidance of communicating Mrs. D’s
medications to additional members as well as the nurse providing discharge (Hain, 2017).
Refuting the same, it must be noted that the nurse provided adequate discharge education to Mrs.
D in terms of pain medication for the best possible and beneficial treatment of her pain-
associated symptoms. However, nursing ethical principles of beneficence must be performed in
congruence with non-maleficence which necessitates the consideration of practices associated
with negligible levels, if not any, harm to the patient (Hoskins, Grady & Ulrich, 2018). In such
case, administration of anti-coagulant and pain medication therapy was the least harmful,
evidence-based treatment for Mrs. D, which was not only communicated to the patient during

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discharge but the inadequate application of the same, also resulted in occurrence of ultimate
harm – which is, death to the patient.
Topic 3: Legislation
Significance of Federal Legislation
The federal legislation responsible for the regulation of medications in Australia, is the
Therapeutic Goods Administration (TGA). The significance of the TGA lies in its core
functioning principles of ensuring positive health outcomes in among the population of Australia
by monitoring effectiveness and timeliness in the regulation of medications, complimentary
medicines, medical equipment, diagnostic instruments as well as blood and tissue samples, all
collectively known as therapeutic goods (Department of Health, 2019). Hence, the significance
of the TGA lies in is regulation underlying the manufacturing, advertisement and supply of all of
the above in noted healthcare organizations, pharmacies and by clinicians, coupled with ensuring
an application of a risk-based approach where both high and low risk medications undergo
safety, efficacy and quality assessment (Kulkarni, 2017).
Legislative Schedules
The legislative schedule assigned for paracetamol medications is ‘Schedule 4’ – hence,
making it a ‘prescription only medicine’ (Nursing and Midwifery Board of Australia, 2019).
Hence, this means that such drugs can only be administered by the nurse after careful
monitoring, evaluation and authorization from health professionals, despite their low risk of

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being abused or causing drug dependence (Department of Health, 2019). The legislative schedule
assigned for the medications of oxycodone and fentanyl is ‘Schedule 8’ – making it a ‘Controlled
drug’ (Nursing and Midwifery Board of Australia, 2019). Hence, this means that such drugs can
only be supplied and administered by authorized health professionals such as pharmacists of
medical practitioners, considering their high possibilities of being abused and causing
dependence (Department of Health, 2019).
Differences
The storage of schedule 4 drugs in the health organization must be performed by
authorized health practitioners or the registered nurse and kept in a locked cabinet which can be
accessed by an authorized health practitioner or by any other individual after being supervised by
the authorized personnel. The same authorized storage principles apply to schedule 8 drugs
except that while schedule 4 drugs can undergo storage at usual places of practice, the schedule 8
drugs are permitted to be stored only in drug safes which are approved (Government of Western
Australia, 2019).
For documentation, the registered nurse must document schedule 4 and 8 drugs in detail
by recording the timing and date of medication retrieval from the inventory along with the form,
dosages and number of containers of every controlled substance present in the healthcare
organization. To reduce possibilities of errors and confusion, it is recommended that each
schedule 8 drug is documented in a separate page along with details of the drug as well as brand
name of the controlled medication (Small et al., 2016).

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Nursing Responsibilities
Upon noticing a discrepancy between the quantity and volume of a schedule 8
(controlled) medication stock and the entry made in the ward book, the nurse must immediately
notify the same to the highest authority who is permitted to administer or ensure supply, order
and storage of such drugs in the healthcare organization (Hope, Dickfos & King, 2016).
Likewise, the nurse or the authorized health practitioner, upon noticing a discrepancy, in the
register must immediately notify the Department of Health’s Chief Executive Officer, within a
maximum of 24 hours, using the Corporate Governance Directorate. After reporting of such
discrepancies using an approved form of notification, the reasons underlying the same must be
followed up and reviewed, preferably by the Pharmaceutical Services Branch of the Department
of Health (Hua, Shen & Ge, 2015).

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