Example Of Medication Error Case
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CBS/AP December 4, 2014, 6:11 PM Hospital medication error kills patient in Oregon Comment Share Tweet Stumble Email A hospital in Bend, Oregon, says it administered the wrong medication http://www.medscape.com/viewarticle/490499 to a patient, causing her death.Loretta Macpherson, 65, died shortly after she was given a paralyzing agent typically used during surgeries instead of an anti-seizure medication, said Dr. Michel Boileau, chief clinical officer for St. Charles Health System.He said Macpherson stopped breathing and suffered cardiac arrest and brain damage.Macpherson came into the ER two days earlier with medication http://www.cbsnews.com/news/oregon-hospital-medication-error-kills-patient/ dosage questions after a recent brain surgery.Three employees involved in the error have been placed on paid leave. The organization is conducting an investigation, but doesn't yet know how the error occurred, Boileau said.The investigation is looking at every step of the medication process: from how the medication was ordered from the manufacturer, to how the pharmacy mixed, packaged and labeled the drug, to how it was brought to the nurses and administered to the patient."We're looking for any gaps or weaknesses in the process, or to see if there has been any human error involved," Boileau said.The hospital notified the Deschutes County district attorney, who did not immediately return a call for comment.According to the Bend Bulletin, the doctors determined Macpherson needed an intravenous anti-seizure medication called fosphenytoin, but instead accidentally administered rocuronium, which caused Macpherson to stop breathing and go into cardiac arrest, leading to irreversible brain damage. The hospital took Macpherson off life support Wednesday morning.The patient's son, Mark Macpherson told the newspaper he'd recently moved to closer
Verdicts & Settlements Making a Difference News Contact Us Case Evaluation at No Cost 800-866-2889 Medical Professionals http://www.lubinandmeyer.com/cases/medication-error.html on Staff Verdicts & Settlements Verdicts & Settlements Archive Verdicts https://psnet.ahrq.gov/webmm/case/299/right-regimen-wrong-cancer-patient-catches-medical-error & Settlements by Type Search Verdicts & Settlements Medication Error Lawsuit Resulting in Death of Woman Settles for $1.25 Million 2011 Medical Malpractice Trial Report Death of 76-year-old woman from preventable medication error—30 times dose of Lepirudin The plaintiff’s decedent was a 76-year-old woman medication error who died on 11/24/10 from a hemorrhage. Her death occurred following a preventable medication error involving the drug Lepirudin. The patient was given over 30 times too much medication which resulted in uncontrollable internal bleeding and her subsequent death. Her past medical history included cirrhosis with well preserved hepatocellular synthetic function. She also had Type medication error case 2 diabetes, hypertension and hypercholesterolemia, and a history of splenectomy for treatment of severe thrombocytopenia. In August, 2010, she suffered a fall which led to a right humeral fracture. Her fracture was to be managed conservatively. Following this injury, she remained hospitalized at various facilities due to anemia, acute renal failure, urinary tract infections, and an upper extremity blood clot. In November 2010, she was found to be suffering from Heparin induced thrombocytopenia (HIT). It was noted that in light of her HIT, immediate anticoagulation was necessary, and that Lepirudin would be administered. The order was for 0.1 mg/kg/hr in a premixed continuous infusion. It was to be titrated to a PTT level of 50-70. If the PTT was greater than 2.5 times the baseline, then the infusion was to be held for two hours and reinstituted at 50% of the original infusion dose. The PTT was then to be checked in 4 more hours. If the PTT was less than
Me Forgot Password? Login or Sign up for a Free Account My Topics of Interest My CME My Profile Sign Out Home Topics Issues WebM&M Cases Perspectives Primers Submit Case CME / CEU Training Catalog Info Glossary About PSNet Help & FAQ Contact PSNet Email Updates Editorial Team Technical Expert/Advisory Panel Terms & Conditions / Copyright PSNet Privacy Policy External Link Disclaimer Cases & Commentaries Published May 2013 Right Regimen, Wrong Cancer: Patient Catches Medical Error Spotlight Case Commentary by Joseph O. Jacobson, MD, MSc, and Saul N. Weingart, MD, PhD Sections Case Objectives Case & Commentary: Part 1 Case & Commentray: Part 2 References Table Figure Topics Resource Type Cases & Commentaries Approach to Improving Safety Error Analysis Safety Target Ordering/Prescribing Errors Chemotherapeutic Agents Setting of Care Hospitals Clinical Area Medical Oncology Target Audience Health Care Providers Quality and Safety Professionals Error Types Epidemiology of Errors and Adverse Events Near Miss More PPT PowerPoint Presentation (766 K) Download free PowerPoint viewer Share Facebook Twitter Linkedin Email Print Case Objectives Appreciate that chemotherapy administration is hazardous and challenging. Describe the most common types of errors associated with chemotherapy administration. State why errors may be common when chemotherapy is administered in the inpatient setting. Describe the importance of understanding the process of chemotherapy administration and the importance of standardizing the process. Case & Commentary—Part 1 A 48-year-old man with a history of metastatic penile cancer was admitted to an inpatient internal medicine service for his fourth round of chemotherapy. He had three previous uncomplicated admissions where he received a standard protocol of 3 days of paclitaxel, ifosfamide, and cisplatin. The patient received this regimen for 3 days with minimal adverse effects. On hospital day 4, based on his previous admissions for chemotherapy, the patient was expecting to go home. In the morning his bedside nurse for the day came in and stated that she would be giving him his fourth day of chemotherapy. The patient was surprised by this and, before the chemotherapy was administered, asked to speak with the oncology team who was directing his care. After speaking with the patient, the oncology fellow examined the orders in more detail and realized that the incorrect chemotherapy regimen had been ordered for the patient. Rather than the 3-day regimen for m