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).
Ethical Issues Involved
The case described above violated the ethical principle of non-maleficence. This principle involves the obligation to avoid causing harm (Beauchamp & Childress, 2001). It rests on the maxim primum non nocere—that the provider has a duty not to cause harm or injury to patients and not to take actions that could result in harm. This principle captures the complexities of medical practice. The phrase "actions that would harm" acknowledges the field's inherent fallibility, since harm is not always predictable and may result from complications or side effects.
Moreover, tensions arise around allowing patients to die versus actively ending life, the withdrawal or withholding of life-sustaining treatments, intending versus merely foreseeing harmful outcomes, and choosing between ordinary and extraordinary treatments (Hannawa, 2012). Adverse events naturally point to maleficent conduct due to a failure to prevent harm. However, failing to disclose medical errors—or disclosing them incompetently—can itself constitute maleficence. Providers may invoke "therapeutic privilege" and choose not to disclose information, ostensibly for the patient's benefit. Such nondisclosure may cause further harm if needed treatment is delayed as a result (Hannawa, 2012; Beauchamp & Childress, 2001).
The case also contravened the principle of beneficence, which holds that "one ought to help others." The secondary tenet of this principle—"preventing harm from occurring to others"—was likewise not upheld. Nondisclosure of the error could cause further harm to both the patient and the patient's family (Hannawa, 2012).
Legal Issues Involved
In 2001, the Joint Commission on Accreditation of Healthcare Organizations required all hospitals to disclose unanticipated care outcomes to patients and, where appropriate, to their families. Five years later, the National Quality Forum advanced disclosure standards for healthcare institutions and professionals, requiring providers to disclose factual information, apologize for medical errors, and express regret. While the judiciary was slow to respond to these developments, at least 34 states have adopted apology laws that allow clinicians to apologize to patients without fear that the apology will be used as evidence of negligence (Hannawa, 2012).
The tort system—specifically professional liability—provides the primary legal response to patient safety concerns. Professional liability legal rules are designed to serve two goals: the fair compensation of victims harmed by negligent care, and the creation of incentives for professionals to improve practice in order to avoid paying damages (Kohn, Corrigan & Donaldson, 2000). There is near-universal agreement that a patient harmed by medical treatment should have the option of equitable compensation. In most countries in North America and Europe, civil liability is based on individual negligence or fault. However, such regimes are not adequately equipped to serve both of the goals described above (Guillod, 2013). Additionally, the contribution of a hospital's structure, culture, governance, and orientation toward social responsibility to an adverse event is not adequately addressed by existing legal frameworks.
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