There were specific situations that led to the cause of Julie Thao's actions of medication error and the death of Jasmine. The situation could have completely been avoided had Julie followed the code of ethics and avoided shorts to provide proper care for the patient. The state claimed that Thao's mistake was caused by actions, omissions and unapproved shortcuts, however, there were other factors that played a role in her carelessness as well. While failure to comply with procedure has been a factor in the medication administration error, other factors contributed as well. For example, failure to properly use the information system, or to ignore alerts or warnings have also resulted in preventable errors (Nelson, Evan, & Gardener, 2005). At the time of the event, a bar coding system for all medication had been in effect for a duration of two weeks, however, Thao had been gone one of those crucial weeks. Because of her absence, she did not receive the adequate training, instead, she received a sped …show more content…
Another major factor of Thao's medication error was fatigue. That had been picking up extra shifts, including the one in which she worked on the fourth of July. Her lack of proper rest and not giving her mind time to receive those eight hours caused the confusion between the two IV containing the two kinds of medication. Despite the fact that Thao had been a nurse for several years prior to the event, Thao did not follow the proper protocol to ensure that patient's safety. She gave her un-prescribed medication which resulted in Jasmines death. As a result, all these factors played a major role in the tragic death of her patient. If Jasmine took the time to professionally handle the situation correctly by taking care of her well-being by getting the proper sleep and paid closer attention like she should have the outcome of the situation could have turned out drastically
This model is designed to use the need of identifying and correcting errors other than focusing on the punishments of the employee. A line within this culture states that staff are not fired due to a human error. The focus on better the person as a medical professional, since humans can just make mistakes. It was argued that she should have realized that the dose was too much for an infant. The argument back was that a firing a nurse who made a mistake isn’t really solving anything.
The coroner found toxicology to be the result of respiratory depression and the main cause of death of Mrs Herbert. Therefore it is evident from this result that standard 4, medication safety was breached by the health care workers involved within this case. The NSQHS medication safety criteria consists of a number of safety measures health care workers need to meet when handling medications including prescribing, supplying, administering, storing and monitoring patients post administration (Australian Commission on Safety and Quality in Health Care 2012). In this event, the doctor and nurses did not meet this safety requirement when caring for Mrs Herbert. Dr Kurtzer decided to administer an intramuscular injection of 30mg of morphine due
Start by providing a short 4-6-line synopsis of the key elements of the case – and discuss what kind of incident occurred (week 1). In this case, “Medical error kills Hopkins Cancer Patient” by Erika Niedowski, the error was the failure of a planned action to be completed or intended and the use of a wrong plan for instance overdosage of potassium to achieve an aim. These errors were preventable and may not have caused the harm. Preventable adverse drug events and their causes and contributing factors had caused stopped Brianna Cohen's heart.
INTRODUCTION This is the case study of Ms Lynette Maree Young, 46 years old women who died on 29 April 2012 because of shock following Interferon alpha treatment. During the treatment of her in the hospital, failure to early diagnosis of pericarditis and failure to prompt management of side effects of interferon therapy led the situation for death of Ms. Young. The main reason behind the death of Ms Young has happened due to the lack of assessment and inappropriate care provided by the health team including doctors and nurses. This assignment will discuss the cause of Ms Lynette Maree Young death in the context of Coroner’s case, patient safety, tort of negligence and ethical issues that has been identified during the period of treatment SECTION
Missed identification of shock symptoms in Ms. Gadner 2. IV infiltration being missed resulting in her not receiving fluid ordered 3. “Scanty documentation” depriving the physician of information on Ms. Gadner’s current condition 4. Administration of valium and morphine, contraindicated in shock, nursing not questioning the order 5. Didn’t communicate need for transfer to Dr. Dick.
Josie’s death shouldn’t have happened, and would’ve probably been avoided if someone took the time to truly listen to her mother’s concerns. Reading Josie’s story opened my eyes to the dire need of communication between the medical team and patients and/or family members. Sorrel, Josie’s mother, tried numerous times to alert the medical team of the changes observed in her daughter, yet no one listened. She highlights the severe breakdown in communication and the necessary steps needed to rectify our medical
Staff work with the same residents day after day, and the CMs know what the residents take for medications every day. An intervention for preventing the medication error from happing again is implementing a better system in which the medications are administered. First, the medication administration record (MAR), could become computerized. This way it makes it difficult for the CM to sign off all the medications at once for the residents when setting them up. This would alert the nurse that all the residents were getting their medication at the same time, which is impossible.
The Victoria Government Department of Human Services (2012) stated “the freedom to make decisions which affect our lives is a fundamental right that each of us should enjoy”. The decisions we make in our lives represent who we are and how we want to be perceived by the world – whilst taking into consideration our own morals, beliefs and goals. Supported decision-making (SDM) is a process by which “a third-party assists or helps and individual with an intellectual or cognitive disability to make a legally enforceable decision for oneself” (Kohn & Blumenthal, 2013). May & Rea (2014) stated that “supported decision-making assumes that all people, regardless of their ability or disability, have some capacity to be involved in decision making”.
Medication Errors in Healthcare The nursing profession entails many responsibilities that range from providing emotional support to administering medications that could result in death for those receiving care. Approximately 40% of a nurse's day consists of passing medication, a duty that sets their level of liability above many other healthcare professions (McCuistion, Vuljoin-DiMaggio, Winton, Yeager, & Kee, 2018). Despite today's advances in technology and nursing education, the frequency of medication errors is still staggering. To ensure that the benefits of nursing outweigh the risks, nurses look to the Quality and Safety Education for Nurses (QSEN) six core competencies for guidance.
Upon arriving to the unit this morning, I quickly realized today was going to be a chaotic day with the current patient census, and all of the new admissions. I was able to assist the night charge nurse with today’s assignments, while she helped with the code, and the day began. I informed my team that today was going to be a long day, and encouraged them to use each other and myself for help. I recommended they taking a few minutes to coordinate their work after receiving report. At 0745, when Jane informs me that the patient in 408 has fallen, I am quick to get into the room and do an assessment again.
Interpersonal skills and effective communication among healthcare professionals are at the core of quality patient care. Interpersonal skills are defined by Rungapadiachy (1999, p.193) as “those skills which one needs in order to communicate effectively with another person or a group of people”. It includes verbal communication, non-verbal communication, listening skills, negotiation, problem-solving, decision-making, and assertiveness (Skills You Need, n.d.). The National Joint Committee for the Communicative Needs of Persons with Severe Disabilities (1991) defined communication as, “Any act by which one person gives to or receives from another person, information about that person 's needs, desires, perceptions, knowledge, or affective states.
This is an important issue because by trying multiple techniques to get Vivian’s heart pumping again, such as CPR and electric shock paddles, he violates the ethical principle of autonomy. He refuses to respect what the patient has decided is best for her mind, body, and soul and instead steals her right to that decision away from her. It is clear that this was a deliberate act because Susie exclaims that the order was put in a day before and he even looked at it himself (Bosanquet & Nichols, 2001). He was not lazy and forgot to check her chart, he knew the order was there and made a methodical choice not to abide by it. His motivation to revive her is to keep her alive because she aids his research.
The practice of health care includes many scenarios that have to do with making adequate decisions when it comes to a patient’s life, and the way they are treated. Having an ethical code in all health care organizations is very important, because it helps health care workers with reaching a suited and ethical decision when it comes to the patient. In health care, patient will always be put first, and their autonomy will always be respected. Nevertheless, when there is a situation where a patient might be in harm, or might be making their condition worse because of the decisions they made. Health care workers will always be there to