Medication Errors: Nursing Ethics, Law, and Patient Safety
This paper examines a fatal medication error case in which an overworked nurse's preparation of both an epidural anesthetic and a penicillin drip resulted in the wrong substance being administered intravenously to a laboring patient. Drawing on deontological, utilitarian, and situational ethical frameworks, the paper analyzes the responsibilities of individual nurses, hospital administrators, and systemic organizational culture. It argues that medical errors are rarely the fault of a single actor and that improving communication, enforcing safety protocols such as bar-code verification, and fostering a culture of openness are essential to reducing preventable harm in healthcare settings.
- Introduction: Medical errors, nurse obligations, and ethical complexity
- The Case: Fatal epidural mix-up involving overworked nurse
- Personal Values and Ethical Responsibility: Systemic failures versus individual nurse culpability
- Ethical Viewpoints: Deontological, utilitarian, and situational ethics compared
- Ethical Decision-Making Model: Communication gaps, bar-code failures, and shared blame
- Concluding Remarks: Culture of openness as key to patient safety
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What makes this paper effective
- The paper grounds abstract ethical frameworks — deontological, utilitarian, and situational — in a specific, real-world case, making the theoretical analysis immediately applicable and concrete.
- It distributes blame analytically rather than assigning it to one party, acknowledging the nurse's role while consistently pointing to systemic and administrative failures as root causes.
- The conclusion ties personal professional development to broader institutional culture, giving the argument a forward-looking, constructive dimension rather than ending with judgment alone.
Key academic technique demonstrated
The paper demonstrates multi-stakeholder ethical analysis: it applies competing ethical frameworks to the same scenario and evaluates each for adequacy. By showing that neither a purely deontological nor a purely utilitarian lens fully accounts for the complexity of clinical environments, the paper argues for situational ethics — a position reached through reasoned comparison rather than assertion.
Structure breakdown
The paper follows a classic case-study structure: a brief introduction establishing stakes, a narrative description of the incident, a values-oriented discussion of who bears responsibility, a comparative ethical-frameworks section, an applied decision-making analysis, and a reflective conclusion. Each section builds on the previous one, moving from description to analysis to prescription.
Introduction
Medical errors cost lives, and they cost healthcare organizations valuable resources. Nurses are often uncertain about their ethical as well as legal obligations, especially within a complex, constantly changing, global healthcare marketplace. Few medical errors are completely straightforward. Most incidents involve multiple actors and numerous stakeholders. Nurses are increasingly challenged to combine deontological with utilitarian ethical viewpoints — an endeavor that is as demanding 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 had spent the previous night sleeping in the hospital. At the time of the incident, she was caring for two patients. One was a pregnant teenager admitted for labor induction. The patient had 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 part of the labor routine and retrieved it so she could show the patient the instructions when the time came. She left the bag of epidural anesthetic and the bag of penicillin side by side at the patient's bedside. No one on the healthcare team, including the nurse, had used the bar-code verification 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 caesarean section. When the nurse learned that an internal investigation had been launched, she resigned. Shortly thereafter, the attorney general filed criminal charges against her. She was charged with felony abuse of a patient causing great bodily harm, carrying a maximum sentence of ten years in prison.
Personal Values and Ethical Responsibility
This case raises a number of ethical issues relevant to all healthcare 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 those errors are addressed and remedied is almost always an ethical concern. There are ethics related to human resources and how to handle nurses like the one in this case. Furthermore, ethical issues are also at stake when it comes to hospital procedure, which is why administrators bear significant responsibility for many medical errors.
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 must recognize what they can do to eliminate — or at least reduce — the incidence of error.
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