HLT-313V Topic 2 DQ 1

Using the GCU Library, locate and summarize an allied health malpractice or negligence case study. If possible, select a case within your chosen field of study. What went wrong? What workplace safety, risk management, and/or quality improvement steps were involved? What could have been done differently? If you were in charge of making sure this type of event never occurred again, what steps would you implement into the risk management plan?
You are required to use and cite a minimum of two references from the GCU Library to support your response.

Solution

The phrase “to err is to human” applies in all aspects of human life, including in the healthcare practice, where it is the expectation that all healthcare personnel should be diligent in their work to deliver quality healthcare services to the patients. In some instances, the healthcare personnel find themselves in medical negligence and malpractice situations. A case of medical negligence involved Julie Thao, an obstetric nurse at St. Mary’s Hospital in Madison, who gave the wrong medication to Jasmine Gant, a 16-year-old patient, leading to her death. In this case, the patient was to receive antibiotics; however, the nurse accidentally gave an epidural anesthetic, leading to the death of the patient who was in labor (Zajicek, 2021). All the hospitals have protocols and requirements for the nurses and healthcare personnel to check and confirm the identity of the medications before giving them to the patients; however, in this case, the facility did not have a quality mechanism to differentiate medicines if they had similar casing or packages.

Managing and preventing the risk of such medication errors requires proper mechanisms, such as implementing a system to enhance the identification and verification of medications. For instance, the hospital could have barcode identification of medications to help differentiate medication even if they have the same or similar packaging (Pruitt et al., 2023). In addition, the nurse could also follow the strict medication administration protocols and ensure she administers the correct medication. This medication error resulted from the nurse being overwhelmed and working long hours; therefore, the hospital could ensure the nurses have manageable work shifts to prevent burnout among the staff. A risk management plan to prevent such an error is to use barcode identification methods for all medication, train and retool staff, and manage work schedules for all nurses to ensure safety.

References

Pruitt, Z. M., Kazi, S., Weir, C., Taft, T., Busog, D. N., Ratwani, R., & Hettinger, A. Z. (2023). A systematic review of quantitative methods for evaluating electronic medication administration record and bar-coded medication administration usability. Applied Clinical Informatics, 14(01), 185–198. DOI: 10.1055/s-0043-1761435

Zajicek, J. (2021). Student Note: To Err is Human, Unless You Are a Healthcare Provider. Belmont Health Law Journal, 4(1), 5. https://repository.belmont.edu/healthlaw/vol4/iss1/5

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