Case Study Medication Error Dealing With an Ethical Dilemma

Medication Error

Medical errors cost lives, and they cost health care organizations valuable resources. Nurses are often confused about their ethical as well as legal obligations, especially with a complex, constantly changing, global healthcare marketplace. Few medical errors are completely straightforward. Most incidents involve multiple actors and numerous stakeholders. Nurses are being increasingly challenged to combine deontological with utilitarian ethical viewpoints, an endeavor that is as challenging as the work of healthcare itself.

The Case

(from Hurley & Berghahn, 2010)

A nurse with 16 years of experience was working her third shift in 24 hours, one of which was a double shift. She spent last night sleeping in the hospital. Currently, the nurse was caring for two patients. One was a pregnant teenager admitted for labor induction. The patient tested positive for streptococcus, and a medical resident wrote an order for penicillin.

To prepare for the patient's procedure, the nurse removed the medications ordered for this patient. Although the anesthesiologist had not yet ordered the epidural anesthetic, the nurse considered it to be part of the labor routine and got it ready to show the patient when it was time to give her the instructions. The nurse left the bag of epidural for the patient to read, and also the bag of penicillin ready by the patient's bed. No one on the health care team, including the nurse, had used the bar code system. As a result, a different nurse administered the epidural anesthetic intravenously instead of the antibiotic.

The patient died, but the baby was saved via an emergency caesarian section. When the nurse learned that an internal investigation had been launched, she resigned. Soon thereafter, the attorney general filed criminal charges against the nurse. She was charged with felony abuse of a patient causing great bodily harm. The maximum sentence would have been ten years in prison.

Personal Values

This case raises a number of ethical issues relevant for all health care workers and administrators. As Erlen (2001) states, "Nurses are taught procedures so that they are less likely to make mistakes. Yet nurses do make errors," (p. 82). Errors are not in and of themselves ethical dilemmas. However, how to address and remedy those errors are almost always ethical concerns. There are ethics related to human resources, and how to handle nurses like the one in this case. Furthermore, there are also ethical issues at stake when it comes to hospital procedure, which is why administrators bear the brunt of responsibility for many medical errors. The nurses are often the ones who bear the blame for medical errors. However, "changing the health care system will help nurses to promote patient welfare, lessen the chance of harm, and reduce the likelihood of medication errors occurring," (Erlen, 2001). If the problem of medical error is systemic, then administrators need to recognize what they can do to eliminate or at least reduce the incidence of error.

Ethical Viewpoints

Harm to patients is the primary ethical infraction with medical errors that are preventable. However, many medical errors are related less to a nurse's negligence and more to disjointed organizational culture in a profit-driven health care system. A profit-driven health care system itself is ethically incorrect, as it is impossible to value both shareholders and patients. The current healthcare model is based on strict utilitarian ethics. For example, inducing labor in pregnancy is not generally necessary but it takes place in order to facilitate bed turnovers in maternity wards. The decisions made on a for-profit basis in hospitals can easily be viewed as unethical from a deontological standpoint.

Yet there are inherent contradictions and hypocrisies built into the presumably utilitarian system. A deontological model often provides a more appropriate framework in healthcare. Yet a deontological model is also flawed because it presumes ethical absolutes (Aiken, 2004). Nurses operate in complex environments that cannot be constrained by rigid ethical frameworks. Each situation must be considered separately. Therefore, situational ethics are the most appropriate to apply in most health care situations. The rights of nurses as well as patients also need to be considered. Whether the ethical decision is rights-based or duty-based is also important to consider.

Ethical Decision-Making Model

Erlen (2001) states, "several ethical issues may arise as a result of medication errors: harm to patients, whether to disclose the error, erosion of trust, and impact on quality care." Harm to patients is not an ethical problem when the medical error was a genuine accident, as opposed to being linked to negligence. In the case study above, the nurse was clearly being overworked. The systemic problems of how the hospital was run were not being considered judiciously, but they should be. One glaring problem in this case is how the nurse was able to remove a potentially dangerous epidural from the system without the anesthetist's approval. The administrator of the hospital, not the nurse, is to blame for this infraction.

Furthermore, it is unclear who hooked up the epidural to the intravenous feeder. Because the bag of epidural was labeled clearly, the lack of bar coding system should not have been an issue. Reading the package should be common sense. Even so, the bar code system exists for a reason. The nurses should be using the bar code system and therefore do share at least some of the responsibility for negligence.