Legal and Ethical Issues of a Medical Error Case

Legal and Ethical Issues of a Medical Error Case
In the case study "Understanding the Causes and Costs of Medication Errors”, a Denver hospital acknowledged that a medication error had led to the death of a day-old infant, born in 1996 to a mother with a prior history of syphilis. Because the patient’s parents spoke only Spanish, communication was difficult. This factor, coupled with the fact that the hospitals’ physicians, nurses, and pharmacists, were unfamiliar with the treatment of congenital syphilis and had limited knowledge about the drug, led to the ultimately deadly penicillin dose. Evidence in the case showed that more than 50 latent and active failures had occurred throughout the medication-use process, such as poor syringe labeling, pharmacy mistakes, and confusing drug information (National Research Council, 2007). The three nurses responsible for treating the patient were later charged with negligent homicide.
Legal Aspects of this Case
Four elements must be present for negligence; duty to care, breach of duty, injury, and causation. Negligence is a civil personal wrong of unintentional commission or omission of an act a reasonable prudent person would or would not do under similar circumstances (Pozgar, 2013). According to the National Coordinating Council for Medication Error Reporting and Prevention, a medication error is “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer (2014).” Though technically, no federal laws were broken in this case, death could have been prevented had the nurses noticed the 10-fold overdose or the manufacturer’s label on the syringe reading “IM use only”. The U.S. Food and Drug Administration (FDA) and the Institute for Safe Medication Practices (ISMP) state that some abbreviations, symbols and dose designations are frequently misinterpreted and lead to mistakes that result in patient...