The issue of medical errors presents a serious public health concern that threatens the safety and wellness of patients. The subject of medical errors has been a controversial topic ever since the movement of patient safety was initiated. As cited by Anderson and Abrahamson (2017, p. 13), medical errors account to over 250,000 deaths per annum in the United States, which rates the issue as the third leading cause of mortality. Despite the high numbers of mortality attributed to medical errors, it is astonishing that only 10% of these cases are publicized or reported (Waeschle, Bauer, & Schmidt, 2015). Although this could adversely expose caregivers and initiate litigations from the affected patients and families, publicizing medical errors could enhance professionalism and safety, and hence reduce more errors.
In 2014, a medical error occurred at St Charles Bend, causing the death of a woman aged 65. Loretta Macpherson had visited the hospital seeking medication after experiencing anxiety barely two weeks after she had gone through brain surgery in a hospital at Seattle. After going through the diagnostic processes, the medical staff at St. Charles determined that she required an intravenous medication known as fosphenytoin (Bannow, 2014). However, she was administered with the wrong medication that contained a paralyzing agent. The drug is known as rocuronium, which affected her breathing ability (Bannow, 2014). She later experienced a cardiac arrest that led to irreversible damage to the brain. She died two days later after the administration of the paralyzing agent.
Although making errors is human nature, the underlying reason a pharmacist included the wrong medication on the IV bag remains unknown. The nurse who was taking care of Ms. Macpherson ordered an anti-seizure drug, which was received correctly at the pharmacy department as revealed after the findings in the electronic medical records. Instead of putting the correct medication, the pharmacist placed a paralyzing agent and labeled it as an anti-anxiety drug as indicated in the prescription. Since the label on the drug specified the correct prescription, Loretta’s caregiver could not discover the mistake; hence, she went ahead and administered it to her patient (Bannow, 2014). After treatment, the fire alarm went off, and the caregiver closed the doors to protect the patient. After twenty minutes, the nurse in charge realized the medical error, but it was too late to reverse the adverse effects of the drug.
As anyone would expect, Macpherson’s family received the news about the medication error with anger. One of her sons who had been taking care of her said that the family realized about the mistake after the mother went into cardiac arrest. They immediately demanded an explanation from the hospital, which took several days before it could give a comprehensive and informed report (Bannow, 2014). Although this was not the reason, the family thought that someone had administered the medication and closed the door to prevent her from seeking help. The family went public about the issue, and almost all media outlets were informed. The family believed that publicizing the issue would lower the rates of medication error and if possible ensure that no other individual would experience such pain and suffering. Besides, the family also went to court to establish punitive measures to the hospital. Therefore, to avoid such occurrences in the future, hospitals should protect the lives of their patients by ensuring that safety precautions are observed.
Understanding the organizational structure should reveal how the problem occurred and how it could be prevented in the future. In Macpherson case, the nurse in charge realized that a medical error had transpired. Although the exact details of how the problem escalated through the chain of the hospital command are not provided, it is evident that the nurse in charge tried to understand the cause of convulsions and cardiac arrest. After investigating, the nurse found that the content in the IV bag was different from what she had prescribed (Bannow, 2019). She reported to the nurse manager, who informed the operations manager who escalated the case to clinical informatics. The information was communicated to both the chief information officer and the chief executive officer, Mr. Boileau. In this case, the hospital’s administrator had the role of informing the family about the medication error.
Incidences of medical errors can affect the organizational metrics of the administrator in various ways. First, they negatively influence the patient’s outcomes. Secondly, they extend the period of hospitalization and hence increase the cost of medication. I believe that the board of trustees should be relayed with the exact details of how the medication error occurred. In such a highly publicized issue, inadequate disclosure of information could lead to mistrust from the board of trustees who have the responsibility of overseeing the hospital’s operations. Indeed, it was difficult to solve such an issue without the boards’ input since they play an integral role in the management of the organization. Therefore, the administrator should be efficient and effective in communicating the issue to both the board of trustees and the family.
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