Medication Errors, Ethics, and Organizational Responsibility in Healthcare
This paper analyzes a fatal medication error at a hospital in Bend, Oregon, in which a patient died after receiving a paralyzing agent instead of an anti-seizure medication. Drawing on biomedical ethics principles and legal frameworks, the paper examines how the incident violated the principles of non-maleficence and beneficence, and how disclosure obligations under Joint Commission standards and state apology laws intersect with professional liability. Environmental contributors such as distraction, poor labeling, and caregiver fatigue are explored alongside organizational factors including drug storage practices and staff education. The paper concludes with recommended systemic changes—covering drug information systems, packaging standards, and the expanded "five rights" framework—to reduce the likelihood of similar errors in the future.
- Case Overview: Fatal Oregon medication mix-up described
- Ethical Issues Involved: Non-maleficence and beneficence violations analyzed
- Legal Issues Involved: Disclosure standards and liability frameworks examined
- Environmental Factors and Contributing Conditions: Distraction, fatigue, labeling, and storage risks
- Organizational Changes to Prevent Future Errors: Structural reforms for safer drug administration
- Resources Required for Future Prevention: Five rights framework and technology solutions
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What makes this paper effective
- Grounds its analysis in recognized biomedical ethics principles—non-maleficence and beneficence—applying them directly to a concrete, real-world case rather than discussing them in the abstract.
- Integrates multiple disciplinary perspectives (ethical, legal, environmental, and organizational) to build a comprehensive picture of how medication errors occur and how they can be prevented.
- Moves logically from problem identification through causal analysis to actionable recommendations, giving the paper a clear applied-policy structure.
Key academic technique demonstrated
The paper demonstrates applied ethical analysis: it names specific moral principles from the Beauchamp and Childress framework, explains their content, and then tests whether the case satisfies or violates each principle. This technique—identify principle, define it, apply it to facts—is a transferable model for any healthcare ethics writing assignment.
Structure breakdown
The paper opens with a factual case narrative, then moves through two analytical sections (ethics and law), followed by causal/environmental analysis (distraction, fatigue, labeling, storage), and closes with organizational and resource-based prevention recommendations. Each section is self-contained but contributes to a cumulative argument that systemic reform, not individual blame alone, is the appropriate response to preventable medication errors.
Case Overview
A hospital in Bend, Oregon administered incorrect medication to a patient, Loretta Macpherson, age 65, who passed away shortly after receiving a paralyzing agent typically used during surgery instead of the anti-seizure medication she required. The patient's breathing stopped, followed by brain damage and cardiac arrest. An investigation examined the entire medication process: from ordering drugs from manufacturers, mixing at the pharmacy, and packaging and labeling, to how nurses receive and administer drugs to patients. Gaps and weaknesses in each stage were reviewed to assess the potential for human error (CBS, 2014).
Physicians had determined that the patient required fosphenytoin, an intravenous anti-seizure medication, but rocuronium was accidentally administered instead. This caused Macpherson to stop breathing and suffer a cardiac arrest, resulting in irreversible brain damage. She was later removed from life support (CBS, 2014).
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