Medication Error
Medical errors cost lives, and they cost health care organizations valuable resources. Nurses are often confused about their ethical as well as legal obligations, especially with a complex, constantly changing, global healthcare marketplace. Few medical errors are completely straightforward. Most incidents involve multiple actors and numerous stakeholders. Nurses are being increasingly challenged to combine deontological with utilitarian ethical viewpoints, an endeavor that is as challenging as the work of healthcare itself.
The Case
(from Hurley & Berghahn, 2010)
A nurse with 16 years of experience was working her third shift in 24 hours, one of which was a double shift. She spent last night sleeping in the hospital. Currently, the nurse was caring for two patients. One was a pregnant teenager admitted for labor induction. The patient tested positive for streptococcus, and a medical resident wrote an order for penicillin.
To prepare for the patient's procedure, the nurse removed the medications ordered for this patient. Although the anesthesiologist had not yet ordered the epidural anesthetic, the nurse considered it to be part of the labor routine and got it ready to show the patient when it was time to give her the instructions. The nurse left the bag of epidural for the patient to read, and also the bag of penicillin ready by the patient's bed. No one on the health care team, including the nurse, had used the bar code system. As a result, a different nurse administered the epidural anesthetic intravenously instead of the antibiotic.
The patient died, but the baby was saved via an emergency caesarian section. When the nurse learned that an internal investigation had been launched, she resigned. Soon thereafter, the attorney general filed...
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