Pharmacotherapy in Action


Pharmacotherapyin Action

Pharmacotherapyin Action

Pharmacotherapyrefers to the treatment through administering a specified drug doseto a patient. In the United States (U.S), Smetzer et al. (2010)argued that a minimum of 44,000 to a maximum of 98,000 patients dieannually due to the errors made by nurses, doctors, and otherhealthcare practitioners. Furthermore, an additional 100,000 peoplelose their lives every year due to the hospital infections that arepreventable. Above all, the mistakes that involve medications causeharm to approximately 1.3 million health patients every year in theU.S as indicated by the Food and Drug Administration record (LANDRO,2010). Therefore, this paper provides an exposition of a selectederror occurrence, its impact on the individual or group, themalpractice consequences on the healthcare system, correctivemeasures, and the results of the intervention.

ErrorOccurrence, Type, and Significance

InJuly of the year 2006, a patient aged 16 visited St. Mary’sHospital, found in Madison, to give birth to her child. During theprocess of care within the hospital, the nurse responsible (JulieThao) confused a bag that contained epidural painkiller forpenicillin and connected it to the intravenous line that drained thedrug into the bloodstream of Jasmine Grant, the expectant patient(Smetzer et al., 2010). The reasons as to why Jasmine mistakenlyadministered the epidural pain medicine intravenously included thefollowing. First, the nurse was suffering from fatigue during thetime of the error as a result of working a double shift the previousday. Second, there was failed safety systems related to the recentintroduction of bar coding, but nurses were not adequately trained onhow to use it. Finally, the bags that contained antibiotics and paindrugs compared physically, and were accessible with the same cathetertype. Nevertheless, the nurse accidentally infused an epidural routedrug via the peripheral intravenous line, and that caused serioustensions within St. Mary’s Hospital (LANDRO, 2010).

Impactof Error on the Individuals

Theinfusion of the epidural painkiller into the bloodstream of JasmineGrant by nurse Thao had severe effects on the patient. What followedwith the prescription was a sudden heart collapse of the 16-year-oldpatient. Although her baby was safely delivered via caesareansection, Ms. Grant did not survive to see her progeny because themedical team could not resuscitate her. In other words, a patientdied because of an error that could have been avoided, while theneonate was meant to tolerate a life without a mother (LANDRO, 2010).Furthermore, the hospital fired Ms. Thao following the incident.After that layoff, the nurse faced state prosecution for criminalnegligence. Nonetheless, the nurse had to struggle to defend herselfwith no income or financial resources against the subsequent trials.Although she was to be held responsible for the malpractice, it wasunjust of her organization to withdraw the support she needed at thetime. In any case, Thao was assigned more shifts by then, and thataffected her later performance. Concerning the court ruling, Thao’slicense was suspended. Consequently, she had to face several years ofthe ban from serving any healthcare entity that received Medicare’sfederal funding (Smetzer et al., 2010).

Impactof the Error on the Healthcare System

Theoccurrence of the medication error revealed a lot about St. Mary’sHospital. First, the healthcare system had fewer workers, and thatexplained why Thao was assigned two shifts before the malpracticehappened the next day (Smetzer et al., 2010). Secondly, it was clearthat the institution did not invest in employee training concerningthe use of the newly introduced technology on bar coding system.Additionally, the organization was disorganized in the way itpackaged medications the containers with painkillers resembled thosewith antibiotics, and the nurses could confuse the contents easily.Finally, there was a violation of policy in which the similarmedications that resulted in the error were brought into Jasmine’sroom before any orders were made. The revelations above had adverseeffects on the image of the hospital, which, apart from facingpublic/media criticism, also paid huge sums of money as compensationdue to the loss. Specifically, St, Mary’s management covered atotal of USD 1.9 million to resolve the malpractice suit presented bythe family of Grant. Also, the hospital officials had to attend courtproceedings and fight to prevent the state from bringing criminalcharges to the organization (LANDRO, 2010).

CorrectiveMeasures Taken for the Error that Occurred

Theexternal and internal scrutiny regarding the safety of the hospitalafter the medication error resulted in a number of actions in thehospital. The first obvious corrective measure was the lay-off ofnurse Thao for her failure to observe accuracy in therapeuticadministration. Second, the institution implemented safety nets andprotective devices to aid in promoting the safer behavioral decisionsfor the health practitioners. Furthermore, St. Mary’s hospitalrecruited more staff, adopted collaborative leadership, and workedtirelessly to train the nurses of how to use new technologiesintroduced in the healthcare system (Appleby, 2016).

Resultsof Corrective Action

Severalresults were realized with the execution of the corrective measuresmentioned above. First, the dismissal of nurse Thao led to herabsorption by TMIT for two years. She served there as apatient-safety partner to Dr. Denham, and advanced as a contractpatient-safety researcher, which the nurse admits has helped her tocope with the despair that accompanied her previous error (Appleby,2016). Back in St. Mary’s, the recruitment of more nurses has ledto a reduction of the frequency of nursing shifts to once a day forevery medical practitioner. Also, the training initiative has coveredover 200,000 nurses the hospital, therefore, has many competentprofessionals who can manage technological changes and make correctdecisions with respect to drug administration. Again, thecollaborative leadership adopted has created an atmosphere ofevidence-based practice. Consequently, nurses currently involve a lotof consultations and inquiries before embarking on the actual medicalprocedure (Lake et al., 2016). The outcome of all the issueshighlighted above has been quality healthcare services that havehelped to rebuild the public image of St. Mary’s Hospital.


Fromthe above discussions, it is patent to conclude that medicationerrors are common in the U.S hospitals and causes many injuries andloss of life among the patients annually. Specifically, the treatmentmalpractices that involve pregnant women are far more extensive inthe country than the other error categories. One incident in St.Mary’s Hospital that resulted in the death of a patient, asexplained above, involved nurse Thao administering an epiduralpainkiller intravenously into the bloodstream of Ms. Grant.Nevertheless, the latter lost her life while the former wasdismissed. The outcome of that event prompted the hospital toimplement corrective measures such as the employee training andrecruitment. That has helped the organization to restore its imageand provide quality healthcare to its patients.


Appleby,J. (2016). IOM: Teamwork Key to Reducing Medical DiagnosticErrors.&nbspBiomedicalSafety &amp Standards,&nbsp46(7),49-51.

Lake,E. T., Hallowell, S. G., Kutney-Lee, A., Hatfield, L. A., DelGuidice, M., Boxer, B. A., … &amp Aiken, L. H. (2016). Higherquality of care and patient safety associated with better NICU workenvironments.&nbspJournalof nursing care quality,&nbsp31(1),24-32.

LANDRO,L. (2010). New Focus on Averting Errors: Hospital Culture.&nbspTheAlabama nurse,&nbsp37(2),18.

Smetzer,J., Baker, C., Byrne, F. D., &amp Cohen, M. R. (2010). Shapingsystems for better behavioral choices: lessons learned from a fatalmedication error.&nbspTheJoint Commission Journal on Quality and Patient Safety,&nbsp36(4),152-152.