Medication Error Case
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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 medication errors case reports Catalog Info Glossary About PSNet Help & FAQ Contact PSNet Email Updates Editorial medication error scenarios Team Technical Expert/Advisory Panel Terms & Conditions / Copyright PSNet Privacy Policy External Link Disclaimer Patient Safety Primer Last medication errors cases court Updated: March 2015 Medication Errors Topics Resource Type Patient Safety Primers Safety Target Medication Errors/Preventable Adverse Drug Events Look-Alike, Sound-Alike Drugs More Share Facebook Twitter Linkedin Email Print Background and definitions http://www.medscape.com/viewarticle/490499 Prescription medication use is widespread, complex, and increasingly risky. Clinicians have access to an armamentarium of more than 10,000 prescription medications, and nearly one-third of adults in the United States take 5 or more medications. Advances in clinical therapeutics have undoubtedly resulted in major improvements in health for patients with many diseases, but these benefits have also been accompanied by increased risks. An adverse https://psnet.ahrq.gov/primers/primer/23/medication-errors drug event (ADE) is defined as harm experienced by a patient as a result of exposure to a medication, and ADEs account for nearly 700,000 emergency department visits and 100,000 hospitalizations each year. ADEs affect nearly 5% of hospitalized patients, making them one of the most common types of inpatient errors; ambulatory patients may experience ADEs at even higher rates. Transitions in care are also a well-documented source of preventable harm related to medications. As with the more general term adverse event, the occurrence of an ADE does not necessarily indicate an error or poor quality care. A medication error refers to an error (of commission or omission) at any step along the pathway that begins when a clinician prescribes a medication and ends when the patient actually receives the medication. Preventable adverse drug events result from a medication error that reaches the patient and causes any degree of harm. It is generally estimated that about half of ADEs are preventable. Medication errors that do not cause any harm—either because they are intercepted before reaching the patient, or by luck—are often called potential ADEs. An ameliorable ADE is one
In Join CBSNews.com Sign in with CBSNews.com - Breaking News Video US World Politics Entertainment Health MoneyWatch SciTech Crime Sports Photos More Blogs Battleground The WH Web Shows 60 Overtime Face to http://www.cbsnews.com/news/oregon-hospital-medication-error-kills-patient/ Face Resources Mobile Radio Local In Depth CBS News Store CBS/AP December 4, 2014, 6:11 PM https://primeinc.org/casestudies/pharmacist/study/812/Medication_Error:_Right_Drug,_Wrong_Route Hospital medication error kills patient in Oregon Comment Share Tweet Stumble Email A hospital in Bend, Oregon, says it administered the wrong medication 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 medication error said Macpherson stopped breathing and suffered cardiac arrest and brain damage.Macpherson came into the ER two days earlier with medication 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, medication error case 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 to care for her. "We didn't get the answer for a couple of days about what had happened, but when they first told us, it was pure anger," he told the paper, adding that he wasn't sure if the family planned to pursue legal action. Boileau told the newspaper this was the first time the hospital has dealt with a situation like this. "We are in the process of that analysis right now. Before we say exactly what happened, we're going to make sure we're accurate about. We do know there was a medication error. We acknowledge that. It's our mistake." Studies show hundreds of thousands of people die every year in the U.S. due to h
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