Medication errors and their serious effects
Medication errors have been observed for several decades, and the effects have been serious, resulting in death and disability. The errors include delivering the incorrect drug, dosage, and dose. The Emily Jerry case is one such case that received a lot of attention in the media. Emily died as a result of an overdose of a highly concentrated sodium chloride that had been placed in her chemotherapy IV bag. This occurred two years after she was diagnosed with a little yolk sac tumor. She was only one and a half years old at the time. After several months of being diagnosed, Emily underwent some surgeries, testing and eventually chemotherapy sessions. Unfortunately, during her last chemotherapy session, a pharmacy technician filled her plastic chemotherapy IV bag with 23.4% of concentrated sodium chloride. The technician had compounded the solution by himself (Emily Jerry Foundation, 2013).
Investigation and the technician's admission
After investigations from the pharmacy board, the cause of Emily's death was established after which the technician was confronted for outrageous error. Although he claimed not to have been aware, he admitted to have had doubts about something not being right but could not tell what it was. When the investigators sought to know if the technician was aware of the risks such a concentration posed to the patients, he denied being aware of the danger (Emily Jerry Foundation, 2013).
Causes of medication errors
The above medication error may have been caused by slips and lapses which are also referred to as unsafe acts, knowledge-based mistakes, and violations. The lapses in most cases occur due to large workloads, distractions, and poor staffing. On the other hand, it could be as a result of misappropriated labeling during the preparation process and during repackaging into smaller units. It could also be as a result of miscommunication of drugs orders, which can occur as a confusion of dosing and metric units, inappropriate abbreviations, confusion of drugs with similar names, and poor handwriting (Keers, Williams, Cooke, & Ashcroft, (2013).
Legal responsibility and ethical considerations
In Emily's case, there is a legal aspect that is profound; failure to observe the procedures and principles of practice regarding the Intravenous (I.V.) therapy skills. The hospital and the technician should take responsibility for the medical error. The institutions supplying IV fluid therapy are considered as an integral part of many patients' care. In reference to Emily's case, it was necessary for the fluids together with the medical treatments to be administered using an efficient and faster method intravenously (Weiss & Kock, 2012). The emergency department at the hospital showed some ethical standards by responding immediately to the patient's mother call for help. They put her on a life-saving machine and did their best to keep her alive. From a legal and ethical perspective, the decision of the hospital to apologize immediately they established the cause of death is a welcome one.
Preventing medication errors
It is crucial that the factors that contribute to the medical errors of this nature are highlighted (Weiss & Kock, 2012). The medical practitioners, as an ethical consideration, are required to express empathy which is critical in creating an understanding with the family of the patient. The legal implications of such an error could include pressing charges for medical negligence, unintentional homicide, or accidental manslaughter. These are serious crimes that can attract millions of dollars to the hospital in addition to the revocation of the practicing license (Weiss & Kock, 2012).
Improving medication safety measures
Some of the most appropriate ways of decreasing this medication error is the provision of a drug guide available to the technician at all times, increase supervision of the junior employees and having proper adequate staffing to avoid overworking the employees. Besides, such small aspects like always adding a zero in front of a decimal point, considering the use of a name alert, and double-checking when carrying out a procedure are critical in ensuring compliance with the regulations. Finally, adherence to the institutional regulations and not overlooking anything will curb similar errors from occurring (Weiss & Kock, 2012).
References
Emily Jerry Foundation, (2013). Emily’s story. Available at https://emilyjerryfoundation.org/emilys-story/
Keers, R. N., Williams, S. D., Cooke, J., & Ashcroft, D. M. (2013). Causes of medication administration errors in hospitals: a systematic review of quantitative and qualitative evidence. Drug safety, 36(11), 1045-1067.
Weiss, P.M. & Kock, S. (2012). Medical errors: Disclosure and apology: Physician-patient communication is a critical component of healthcare delivery. Disclosure of medical errors and apology are the most challenging of such interactions, and it’s critical to rise to the occasion. Contemporary OB/GYN. Available at
Http://www.modernmedicine.com/modernmedicine/modern+medicine+Now/Medical-errors-Disclosure-and-apology/ArticlesStandard/Article/detail/777250.
