HCM520_MODULE6_OPTION2_ - Running head HEALTHCARE ERROR IN...

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Running head: HEALTHCARE ERROR IN REAL WORLD 1 Healthcare Error in Real World. Brizette Mack Course Number (HCM 520)-Health Quality, Regulations, and Risk Management Colorado State University-Global Campus Professor: Giaedi, Taher May 16, 2016
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HEALTHCARE ERROR IN REAL WORLD 2 Healthcare Error in Real World. Healthcare error details In an article entitled “Oregon Hospital Apologizes for Fatal Medication Error, Shares Details”, a case of an actual healthcare error at St. Charles Bend is described. In this case, a 65-year-old female patient was a victim of medication error which led to her death. In a notice to the public, the hospital’s chief clinical officer took a step to inform the public what really happened to lead to the tragic error. The St. Charles Hospital says that the patient named Loretta Macpherson arrived at the facility on a Monday, 1 st of December seeking emergency services resulting from a brain surgery she had undergone in another hospital. The hospital goes on to say that the physician who cared for her, correctly administered emergency medication. The process was correctly recorded in the electronic system, and the receiving pharmacist correctly received the order. However, while dispatching the ordered medication for the patient’s treatment, a wrong drug was filled in a correctly labeled IV bag. The physician had ordered for fosphenytoin, but an IV bag labeled ‘fosphenytoin' was issued with a different substance in the bag, which was rocuronium. The drug was received, and since its label correctly matched with the order, the error couldn't be detected. The notice goes on to say that the drug was scanned electronically in the emergency room, and the system couldn’t either detect the error because the label for the drug was what had been ordered. This made it difficult even for the officer in charge to identify that the drug in the bag was different from what was required. The drug was administered to the patient, and soon after that, a fire alarm was triggered to sound due to an occurrence at another department within the hospital. This prompted an officer to lock the door leading to the
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  • Spring '16
  • medical error, Hospital accreditation, Patient safety, Patient Safety and Quality Improvement Act, Iatrogenesis, Healthcare error proliferation model

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