Quaid 2 Medical Errors Case Study

Medical error is the third leading cause of death in the US, right behind heart disease and cancer. More than 200,000 people die annually as a result of diagnostic mistakes and negligence by healthcare professionals (Washingtonpost, 2016). In the healthcare industry, even the smallest mistakes and oversight could lead to severe consequences for both the patient and professionals. A healthcare professional would be held liable for any discrepancies that causes harm. The following case will analyze the ethical issue and negligence that lead to the death of an elderly woman.

Each year, roughly 1.5 million adverse drug events (ADEs) occur in acute and long-term care settings across America (Institute of Medicine [IOM], 2006). An ADE is succinctly defined as actual or potential patient harm resulting from a medication error. To expound further, while ADEs may result from oversights related to prescribing or dispensing, 26-32% of all erroneous drug interventions occur during the nursing administration and monitoring phases (Anderson & Townsend, 2010). These mollifiable mishaps not only create a formidable financial burden for health care systems, they also carry the potential of imposing irreversible physiological impairment to patients and their families. In an effort to ameliorate cost inflation, undue detriment, and the potential for litigation, a multifactorial approach must be taken to improve patient outcomes. Key components in allaying drug-related errors from a nursing perspective include: implementing safety and quality measures, understanding the roles and responsibilities of the nurse, embracing technological safeguards, incorporating interdisciplinary collaborative efforts, and continued emphasis upon quality control.

Atul Gawande in his article “When the Doctor Makes Mistakes” exposes the mystery, uncertainty and fallibility of medicine in true stories that involve real patients. In a society where attorneys protect hospitals and physicians from zealous trials from clients following medical errors, doctors make mistakes is a testimony that Gawande a representative of other doctors speak openly about failures within the medical fields. In this article, Gawande exposes those errors with an intention of showing the entire society and specifically those within the medicine field that when errors are hidden, learning is squelched and those within the system are provided with an opportunity to continue committing the same errors. What you find when you critically analyse Gawande, “When Doctors Make Mistakes essay is how messy and uncertain medicine turns out to be. Throughout the entire article you experience the havoc within the medicine field as the inexperienced doctor misapplies a central line in a patient.

Healthcare workers are not the only ones fearful of exposing medical errors. The medical institutes themselves operate behind a wall of silence. The IOM first recommended a national medical error reporting system in 1999 and despite attempts by then President Clinton, the American Medical Association and the American Hospital Association successfully lobbied against it (Dyess, 2009). As of 2009, only 20 states have a mandatory medical error reporting system and only a fraction of estimated

"Johns Hopkins patient safety experts have calculated that more than 250,000 deaths per year are due to medical error…" (John Hopkins Medicine). This soaring number has caused medical errors to become the third leading cause of death in the United States. For many people, medicine seems foreign and unknown. People who have lost loved ones due to medical error desperately look for a reason, and many times that blame falls upon doctors. Media has put a negative connotation on doctors as well, causing their reputation to plummet whenever a hospital procedure turns badly. A renown surgeon and author, Atul Gawande, uses his knowledge and experience to give people a new perspective on medicine. In the article "When Doctors Make Mistakes," Gawande uses rhetorical appeals: ethos, pathos, and logos to prove the need for a change in the medical systems and procedures. He analyzes how the public looks at doctors, giving a new perspective to enlighten the reader that even the best doctors can make mistakes.

It is shocking to know that every year 98000 patients die from medical errors that can be prevented(Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.), 2000). Medical errors are not a new issue in our healthcare system; these have been around for a long time. Hospitals have been trying to improve quality care and patients safety by implementing different strategies to prevent and reduce medical errors for past thirty years. Medical errors are the third leading cause of death after heart disease and cancer in America (Allen, 2013). In addition medical errors are costing our healthcare system an estimated $735 billion to $980 billion (Andel, Davidow, Hollander, & Moreno, 2012).

Shi, L., & Singh, D.A. (2015). Delivering health care in America: A systems approach (6th ed.). Burlington, MA: Jones & Bartlett Learning.

When assessing whether a no fault regime is better than a negligence rule in dealing with the causes and consequences of medical error, it would seem prudent to first understand the meaning of the term “medical error”. Liang defines medical error as ‘a mistake, inadvertent occurrence, or unintended event in health-care delivery which may, or may not, result in patient injury’ (2000, p.542). The consequence of these errors (or adverse events) that lead to patient injury, and the method by which we determine and administer compensation for such injuries, has been the source of heated debate amongst scholars in recent

Barton, Phoebe Lindsey. Understanding the U.S. Health Services System, Fourth Edition. Foundation of the American College of Healthcare Executives, 2010.

Shi,L., & Singh, D. A. (2015). Delivering Health Care in America: A Systems Approach (6th ed.). Burlington, MA: Jones & Bartlett Learning.

Shi, L., & Singh, D. (2015). Delivering Health Care in America: A Systems Approach (6th ed.). Burlington, MA: Jones & Bartlett, LLC.

Austin, A., & Wetle, V. (2012). The United States health care system: Combining business, health, and delivery. (2nd ed.). Upper Saddle River, NJ: Pearson Education.

We have always been told to give people second chances, well when does that stop? What line do people have to cross to not get a second chance? A mistake could cost a life, or permanently change one life or several lives. In the case of Dennis Quaid, it could have taken both his twins lives. The twins had to be treated with heparin and were supposed to be given 10 mL instead received 10,000 mL, that is 1,000 times the needed amount. The hospital stated later that nobody checked the dosage at the supplier or the pediatric center. This is only one example of how mistakes happen when protocols are not followed. Should the doctors and pediatricians get a second chance, what if this happened and they didn't realize it in time? The doctors didn't end up losing their licenses, but the hospital was sued for $750,000. The twins could have died or suffered permanent damage. Obviously, more could have been done to prevent this accident. The doctors, nurses and other medical professionals have to be held to higher standards when lives are on the line.

The ethical problem with this case is that when the parents called the hospital to see how the infant were doing the hospital said that they were doing fine. They did not tell them that the twins had been given the wrong dose of heparin and where in extreme risk of bleeding out until they arrived at the hospital the next day and were greeted by “ risk management”.

First off, reporting errors doesn’t always occur. Reporting errors in patient care is a conflict of interest for physicians that has led to silence when errors are seen (Lynch). Patients don’t always notice when an error occurs due to lack of medical knowledge but when coworkers see mistakes in patient care, they don’t routinely report them because they see it as turning their back on them (Lynch). Also, in 10 years, roughly 900 physicians were cited for substandard care, negligence, incompetence or malpractice but continues to practice with no action against their licenses (Eisler and Hansen). People don’t think that if they say something, action will be taken to be sure it doesn’t happen again.