Legal Aspects of Medical Errors Various Factors Case Study

Legal Aspects of Medical Errors

Various factors in the health care system are reported to be contributors to medication errors. This work reviews a case study discussed in 'Hospital Pharmacy' (Smetzer and Cohen, 1998) which provides a clear example of the complex nature of the health care system and the process of medication use and how this interrelates to medication safety and quality. The nurse made the decision to administer the medication by IV. The syringe was labeled IM use only. The administration of the medication by IV would prove to be lethal since the drug is insoluble and obstructs blood flow the lungs needed for transferring oxygen to the individual's airways. The baby after it had died was found to not be in need of the treatment after all.

There were 50 latent and active failures that had occurred during the medication-use process and the majority of these failures were not under the control of the nurses. The case study reports, "since most of what people do is governed by the system within which they act, the causes of errors belong to the system and often lie outside the control of individuals, despite their best efforts." (Institute of Medicine, 2007) The legal issues presenting in this case are those due to latent and active failures associated with key elements of the medication-use system. The legal issues are inclusive of the following:

I. Summary of the Legal Aspects of This Case

First among the legal implications in this case is the failure of the hospital to gain the consent of the parents to treat the infant. Second among legal implications is the failure to administer the proper dosage of medication to the infant and the failure to administer the medication in the proper form of delivery. The nurse changed the orders on the medication's delivery and this is a legal issue for the hospital as well. The hospital staff failed to gain consent of the parents for treatment of the child.The hospital did not have the consent of the parents to perform this treatment and from the information available in the case study, the parent would not have consented to this treatment had they been consulted regarding the treatment. This was in direct violation of laws of any U.S. state, which makes a requirement that, a parent provide consent for medical treatment of a minor child.

The pharmacist has a responsibility when filling a prescription to question any prescription "Not in the usual course of professional treatment" and must "exercise sound professional judgment" in the course of filling a prescription. The pharmacist should have been knowledgeable about the medication, in the case he was not should have checked, and then double-checked the prescription whether through calling the physician or checking his own material on the proper dosage for the infant. Failure on the part of the pharmacists is in direct violation of Drug Enforcement Agency regulations.

According to the ASHP Technical Assistance Bulletin on Hospital Drug Distribution and Control, "Any questions arising from a medication order, including the interpretation of an illegible order, should be referred to the ordering physician by the pharmacist." (2011) Also stated by the ASHP Technical Assistance Bulletin on Hospital Drug Distribution and Control is that "All medications should be administered by appropriately trained and authorized personnel in accordance with the laws, regulations, and institutional policies governing drug administration. It is particularly important that there are written policies and procedures defining responsibility for starting parenteral infusions, administering all intravenous medications, and adding medications to flowing parenteral fluids." (2011)

The nurse is also legally liable for having changed the route the medication was administered. Even while the nurse did note that something was wrong, she failed to question the physician. In this case, the physician is not legally liable because he wrote the….....