Answers:
Adverse event:
By reading the article by Stop MICRA (2017), drug administration related error was adverse event identified in the situation. Quaid’s twin baby were supposed to be given a pediatric blood thinner called Hep-Lock. The main purpose for this was to flush out their IV lines and prevent blood clots. However, they were given two dose of Heparin, the adult version of the drug which was 1,000 times higher dose than required for the babies.
Preventive measures in the situation:
The first preventive step that was needed by the nurse when she saw blood oozing out from infants feet and band-aids was to immediately inform the pediatricians and provide other antidotes that could have neutralized the effect of Heparin drug (Ngo, Tan & Olson, 2013). This would have prevented the extent to which the medication worked on both twins and caused damaged. Immediate pharmacological intervention might have prevented the incident.
Quaid’s legal response to the situation:
As such event occurred due to medical negligence which could have been avoided, Quaid’s had all the right to take legal action against the hospital. This was also necessary because in case of any adverse event, patient’s family must be immediately called or informed about the issue. However, no such action was taken and the Quaid’s got to know only when they came to the hospital early the next morning.
Instead of taking legal action against the hospital, the Quaid’s suffered for 41 days. No immediate complain was raised. However, he spent the last nine month investigation about what happened and the reason for such preventable human medical error. Instead of suing the hospital for such negligence, he launched a foundation to find out the remedy for such negligence in health care. I agree that Quaid’s effort of finding solution to the issue is commendable, however his immediate action should have been to sue the hospital. This is because it was a preventable error and legal actions would have alerted health care staffs and drug department to take necessary measures to take extra precaution during drug administration. Evidence has shown that clinician threat disciplinary actions while disclosing such error, however legal actions would have resulted in improvement in error reporting and disclosure (Guillod, 2013).
Role of hospital’s risk management and quality improvement department on the event:
As the event unfolded, the risk management and quality improvement department played a role in handling the case and reporting about the error to Quaid. They would have also played a role in investigating about the main cause of error and the person who was responsible for such negligence. In response this investigation, they could have taken necessary action against the staff.
Preparing an incident report would be most appropriate in this situation as it would clarified all person involved regarding the adverse event. The initial action would be to take necessary action to stabilize the patient and eliminate any obvious threat to patient safety. The incident report can be provided to the hospital officer to further analyse the event and take corrective steps to prevent such event in the future.
Ethical implication:
Error reporting and error disclosure is important and mandatory responsibility in health care setting (Ünal & Seren, 2016). However, the case scenario presented the ethical issues of clinicians and staffs avoiding incident reporting and trying to protect each other from disciplinary action.
Reference
Guillod, O. (2013). Medical error disclosure and patient safety: legal aspects. Journal of public health research, 2(3).
Ngo, A. S. Y., Tan, D., & Olson, K. R. (2013). Low Molecular Weight Heparin Overdose: A 10 Year Case Series. Asia Pacific Journal of Medical Toxicology, 2(2), 68-70.
Stop MICRA (2017). Dennis Quaid talks about his twins and medical Negligence. (2017). YouTube. Retrieved 12 December 2017, from https://www.youtube.com/watch?v=GEDMYsm3Nxs
Ünal, A., & Seren, S. (2016). Medical Error Reporting Attitudes of Healthcare Personnel, Barriers and Solutions: A Literature Review. J Nurs Care, 5(377), 2167-1168
