Case Number: 3-5: A medication Error on the Oncology Unit: Who Has the Final Word?
Step 1: Respond to the Sense That Something Is Wrong – Where in the case is the first indication that an ethical problem/issue is developing? Why? (250 words or less)
There were many ethical issues within this case; the first indication of an ethical problem was the administration of an incorrect medication to the patient. The doctor, administration, and providers involved in the care of the patient must decide what is ethically moral when informing the patient. I believe that it is the patient’s right to know that she received the wrong medication for a number of days. Although no major medical consequences occurred, I believe this error was ethically wrong and violated the patient’s rights.
Step 2: Gather Information – What clinical and situational information is available in the case? What clinical or situational information is needed to effectively analyze the case? (250 words or less)
The clinical information available in this case is that the patient was diagnosed with ovarian cancer and that she was given Lorazepam 2mg instead of her antineoplastic medication for six days. Clinical information that may be useful would be the stage of cancer, when she was diagnosed, and why she was admitted to the hospital. Further clarification on extent of harm would require lab results from before and after the administration of the wrong medication. Situational information offered in this case is that the patient is currently residing in the hospital and being treated by a physician for cancer. I would like to know if anyone is with her at the hospital, her religion or race, and the patient’s ability or inability to communicate...
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...ally, but may also take into consideration that everyone is human and mistakes may occur in any setting. Although, health care professionals should be held to a higher standard and we should do all that we can to ensure errors do not occur. Another issue that needs to be resolved is allowing physicians to write in abbreviations. The use of abbreviations caused an error that could have been prevented if the physician took an extra 15 seconds to write the prescription properly. In a pharmacists’ perspective this issue correlates with the code: A pharmacist respects the values and abilities of colleagues and other health professionals. A pharmacist should respect the physician but should not feel obligated to never question him/her. If the pharmacist filling the medication would have questioned the abbreviation instead of assuming, the error could have been prevented.
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