400418 Health Advancement And Health Promotion

Question According to an article published in the News-Tribune, a 39-year-old woman, who was being treated for breast cancer, died as a result of receiving the wrong dosage of cyclophosphamide (a cancer-fighting agent) and an overdose of another drug meant to keep her from suffering side effects. This happened at a reputable facility that specializes in the treatment of cancer. At least a dozen doctors, nurses, and pharmacists missed the medication error for four days. Her husband reported that she suffered tremendously as the lining of her intestine was shed, resulting in her literally vomiting sheets of tissue. The doctors had reassured the patient and her husband that all was normal. Her heart failed after receiving four times the recommended amount of medication. An autopsy revealed no visible signs of cancer in her body, which indicated that the treatment had worked. Another woman died of a similar mistake two days earlier. Human error was believed to be the only possible explanation, according to the treatment center. Incorrect doses of medication through either dispensing error, administration error, or prescription error can be deadly. Moreover, many adverse events go unreported. What type of event is this? Provide reasons to support your answer. Hospitals perform several types of patient care reviews, usually through a committee. What type of review(s) would be done on this case? What is the process used to identify the cause of this death and who needs to be involved in the investigation, and what tools should be used to analyze the situation? Discuss what kinds of changes are likely to result in an improved system for treating patients using toxic medications. Answer Medication Error Type Of Event The death of the woman was a sentinel event. A sentinel event may occur due to a preventable adverse drug event (ADE). The Joint Commission describes a sentinel event as an unexpected incidence involving either death or serious injury (The Joint Commission, 2017, para 1). The 39-year old woman died since she received a wrong dosage of cyclophosphamide and an overdose of another drug intended to keep her from suffering side effects. Type Of Review A medical peer review would be performed using Six-Sigma approach. A medical peer review consisting of a committee of physicians would examine the conduct of the prescribing physician and determine whether the physician adhered to the accepted standards of care. Blanchard and Rudin (2016) assert that Six-Sigma is a data-driven approach for eliminating defects in a process. The Process Used To Identify The Cause Of This Death Forensic autopsy or medico-legal autopsy is the process used to determine the cause of this death. Forensic autopsy helps to determine the precise cause of death, time of death and circumstance of death (Costache et al., 2014). Law enforcement officer and forensic pathologist need to be involved in the investigation. Radiographic imaging tools and immunohistochemical stains may be needed to analyze the situation. The Changes Likely To Result In An Improved System For Treating Patients Using Toxic Medications Examining the medical history of the patient is important to determine whether they experience allergies. The physician can seek assistance from a medical toxicologist before prescribing to prevent adverse events. For intravenous administration, the physician should ensure the patient is stable before administering the drug. Methods for detecting medication errors should also be used, and they include chart review, computerized monitoring and incidence reporting (Manias, 2013). References Blanchard, J. C., & Rudin, R. S. (2016). Improving Hospital Efficiency Through Data-Driven Management: A Case Study of Health First, Florida. Rand health quarterly, 5(4), 2-6. Costache, M., Lazaroiu, A. M., Contolenco, A., Costache, D., George, S., Sajin, M., & Patrascu, O. M. (2014). Clinical or postmortem? The importance of the autopsy; a retrospective study. Maedica, 9(3), 261-265. Manias, E. (2013). Detection of medication-related problems in hospital practice: A review. British Journal of Clinical Pharmacology, 76(1), 7-20. The Joint Commission. (2017, June 29). Sentinel Event Policy and Procedures. Retrieved from https://www.jointcommission.org/sentinel_event_policy_and_procedures/

400418 Health Advancement And Health Promotion

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