Medication Error Report: A Case Study and Analysis of a Sentinel Event

This report examines a medication error case, specifically a sentinel event involving a patient's death due to a wrong dosage of medication. It highlights the importance of investigating such incidents through forensic autopsies and medical peer reviews, utilizing tools like Six-Sigma to identify the root causes. The report also discusses the need for thorough patient history reviews, consultation with medical toxicologists, and the implementation of various methods for detecting medication errors, such as chart reviews and computerized monitoring. The report aims to provide insights into preventing such errors and improving patient safety in healthcare settings. This is a case study analysis of a medication error to understand the causes and possible solutions to prevent such errors in the future.

Running head: MEDICATION ERROR 1
Medication Error
Student’s Name
University Affiliation

MEDICATION ERROR 2
Medication Error
Type of event
The death of the woman was a sentinel event. A sentinel event may occur due to a
preventable adverse drug event (ADE). The Joint Commission describes a sentinel event as an
unexpected incidence involving either death or serious injury (The Joint Commission, 2017, para
1). The 39-year old woman died since she received a wrong dosage of cyclophosphamide and an
overdose of another drug intended to keep her from suffering side effects.
Type of review
A medical peer review would be performed using Six-Sigma approach. A medical peer
review consisting of a committee of physicians would examine the conduct of the prescribing
physician and determine whether the physician adhered to the accepted standards of care.
Blanchard and Rudin (2016) assert that Six-Sigma is a data-driven approach for eliminating
defects in a process.
The process used to identify the cause of this death
Forensic autopsy or medico-legal autopsy is the process used to determine the cause of
this death. Forensic autopsy helps to determine the precise cause of death, time of death and
circumstance of death (Costache et al., 2014). Law enforcement officer and forensic pathologist
need to be involved in the investigation. Radiographic imaging tools and immunohistochemical
stains may be needed to analyze the situation.
The changes likely to result in an improved system for treating patients using toxic
medications

MEDICATION ERROR 3
Examining the medical history of the patient is important to determine whether they
experience allergies. The physician can seek assistance from a medical toxicologist before
prescribing to prevent adverse events. For intravenous administration, the physician should
ensure the patient is stable before administering the drug. Methods for detecting medication
errors should also be used, and they include chart review, computerized monitoring and
incidence reporting (Manias, 2013).

MEDICATION ERROR 4
References
Blanchard, J. C., & Rudin, R. S. (2016). Improving Hospital Efficiency Through Data-Driven
Management: A Case Study of Health First, Florida. Rand health quarterly, 5(4), 2-6.
Costache, M., Lazaroiu, A. M., Contolenco, A., Costache, D., George, S., Sajin, M., & Patrascu,
O. M. (2014). Clinical or postmortem? The importance of the autopsy; a retrospective
study. Maedica, 9(3), 261-265.
Manias, E. (2013). Detection of medication-related problems in hospital practice: A review.
British Journal of Clinical Pharmacology, 76(1), 7-20.
The Joint Commission. (2017, June 29). Sentinel Event Policy and Procedures. Retrieved from
https://www.jointcommission.org/sentinel_event_policy_and_procedures/