This negligence case was opened due medication error. Medication errors are a leading cause for medical injury. Due to the variety and complexity of medications, the role of a pharmacist was formed to prepare, compound, and dispense medications as it is impossible for nurses or doctors to understand all information needed for safe medication use (Pozgar, 2022, p. 334). In this scenario, the hospital’s pharmacy is being interviewed as an eight week-old infant in the NICU died after being overdosed by an IV antibiotic that had been incorrectly prepared at the hospital’s pharmacy. In this case, the order was sent to the pharmacy and pharmacy technician, Tatiana Velasco, completed the order and put it into the basket for review by a pharmacist. It is required by hospital procedures for a pharmacist to double check a pharmacy technician’s work and initial in a drug dispensed log book before going into the outbox as a completed order ready for a patient. In the process of checking, pharmacist, Barry Longmore, noticed that it seemed too cloudy, but before he could pull Tatiana to check it with him, he was called by the second pharmacy technician, who required a lot of attention compared to Tatiana, for an emergency and set the order next to the outbox to be checked by him later. By the time Barry Longmore got back to the IV antibiotic order, it was no longer there, had been delivered, and it was too late to fix the mistake. He realized that the other pharmacist, who was on lunch break during this time, had gotten back from his lunch break, must have made the assumption that the order fell out of the outbox without looking at the drug dispense log book that was not signed for this order, and gave it to a nurse who came to pick up the order. From this incident, pharmacist, Barry Longmore, believes that policies and procedures need to be changed. His recommendations were to change policy so that when an order is given out the drug dispense log book must be double checked for initials and that their needs to be a procedure for orders that have been initially looked at, and need further checks before going out, but can’t be completed due to emergencies that have to take priority. Paterick and Paterick (2019) discusses this idea of error through discussing skill-based error which is believed to occur due to distractions which humans are prone to. An example of this is giving medications to the wrong patient from lapse in attention to that task (Paterick & Paterick, 2019). Overall, this is a similar situation as the pharmacist’ attention was taken from the primary task and error occurred during this time.
2 Chronicles 19:6-7 states, “Consider what you do, for you judge not for man but forthe Lord. He is with you in giving judgment. Now then, let the fear of the Lord be upon you. Be careful what you do, for there is no injustice with the Lord our God, or partiality or taking bribes” (English standard version, 2001). This must be kept in mind as liability is decided as decisions need to be made through facts as a breach in trust in care and security have occurred and need to be re-established through actions to find answers and solutions for moving forward. To understand the hospital’s liability in this case, duty of care, breach of duty of care, injury, causation, and foreseeability need to be determined. Duty of care was established when the patient was admitted and put under the care of the hospital which means the hospital had a duty to help the patient and not bring further harm. Duty of care was breached when the pharmacy provided an incorrect IV antibiotic. The injury was identified as the death of an eight-week old infant. The causation was labeled as the pharmacy providing an incorrect dosage through an IV antibiotic that’s concentration was too high. The last decision required is in regard to foreseeability, “the ability to perceive or reasonably anticipate that an injury could occur from the act or omission of legal responsibility” (Walker, 2011). In addition, there is no expectation that a person can expect or protect from events that they cannot predict. Thus, this scenario is not foreseeable. This is not foreseeable as the causation was an error in dosage provided to the patient. The original pharmacist who located the error had every intention to fix the error and got called away for an emergency that had to take priority. What was unforeseen in this scenario was another pharmacist coming back from break, not knowing the situation, not checking the log book, and providing the medication to a nurse for the patient anyways. Barry Longmore could not have foreseen this event when he set down an assignment to come back to after the more emergent case was completed. He did not set down the bag with the intent to cause harm. Thus, the hospital is liable, but there is no foreseeability.
