St. Charles Hospital’s Structure and Medication Error

Introduction

Medical mistakes, which are made by hospital personnel, occur in the process of health delivery. Hospital errors and mistakes are considered to be an unintended human act. Makary and Daniel (2016) state that medical error is the third leading cause of death in the United States of America (p. 3). It means that there are more human deaths from medical mistakes than from AIDS in the United States. There are a few types of medical errors such as medication, surgical, technical, administrative errors, misdiagnosis, and others. The article published by CBS News (2014) describes the case of hospital medication error that took place at St. Charles Hospital in Bend, Oregon in December 2014.

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The Incident at St. Charles Hospital

According to CBS News (2014), a hospital patient named Loretta Macpherson, who was a 65-year-old pensioner, died because of cardiac arrest and brain damage that were caused by a paralyzing medicine, improperly prescribed drug (para. 3). Such drug is used during surgeries. Macpherson had brain surgery recently and came to St. Charles Hospital to get a new medication dose.

When CBS News published the article, the hospital was conducting the investigation to find out how the error occurred and who was responsible for it. It is worth mentioning that three employees who were probably involved in the death of Loretta Macpherson were suspended from work. The inspection was conducted very thoroughly; every step was investigated. The hospital St. Charles immediately notified the Deschutes County district attorney.

The relatives of the victim said that they did not get the answer immediately after Macpherson’s death. The hospital representatives revealed the truth a few days later. In the beginning, Macpherson’s son did not know if he would pursue legal action, but he lodged a complaint against St. Charles Hospital shortly afterward. In the end, Deschutes County district attorney did not pursue criminal charges. According to Moore (2016), “a monetary settlement was reached between the family of Loretta Macpherson and St. Charles Hospital” (para. 1) in 2016.

Organizational Structure

To understand how this medical error occurred, it is essential to describe the organizational structure of a standard public hospital system. As Wagner et al. (2014) emphasize “organizational structures does have an impact on the implementation of quality management strategies” (p. 80). Organizational structure varies from hospital to hospital. The whole health care system can be divided into three levels: primary, secondary, and tertiary care. Primary care is specialized in basic curative care; secondary care refers to specialized care that requires more complex treatment, and tertiary care is aimed at consultative healthcare. St. Charles Hospital refers to general hospitals or the secondary level of health care system.

The Likely Scenario of the Incident

It is almost certain that a pharmacy worker gave Loretta Macpherson a paralyzing agent instead of an anti-seizure medication, so it was a patient-related issue, and the nurses were informed first when Macpherson felt ill. Next, this information probably went to doctors and nurse managers simultaneously. They had to report to clinical informaticists who got healthcare administrator’s attention. Finally, the information was given to the chief executive officer and the board of trustees. It is more likely that the information about Macpherson’s case passed through these stages. However, there is a possibility that the hospital administrator was in charge of filling in some blanks, and he could write down incorrect information about medicals. In this case, the administrative assistant was the first stage in the process of making this mistake. It goes without saying that if the hospital administrator fitted into the reporting and escalation of grievances, he would be immediately fired and even convicted in court.

Nevertheless, should the situation be relayed to the board of trustees? The answer seems obvious. Macpherson’ case is serious, and it is not an issue that could be resolved without the board’s input. Thomas et al. (2015) explain “hospitals with boards that paid greater attention to clinical quality had management that better-monitored quality performance; hospitals with boards that used clinical quality metrics more effectively had a higher performance by hospital management staff on target setting and operations” (p. 1304). Full understanding of situations and medical errors and mistakes that occur in different levels of hospital organizational structure will provide new challenges and opportunities for improving the quality of care.

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Conclusion

To sum up, medical errors are common nowadays. One example of hospital mistakes is the publicized story of Loretta Macpherson who died due to improperly prescribing drugs. The Deschutes County district attorney did not pursue criminal charges, and a monetary settlement was reached between the family of Macpherson and St. Charles Hospital. It is almost certain that the pharmacy worker at the hospital mistakenly gave Macpherson a paralyzing drug instead of an anti-seizure medication that led to the patient’s death. However, the hospital administrator may be guilty too. All in all, the information about this situation should be relayed to the board of trustees anyway. It is necessary because some measures have to be taken to learn from this mistake and to prevent such situations in the future.

References

CBS News. (2014). Hospital medication error kills patient in Oregon. Web.

Makary, M. A., & Daniel, M. (2016). Medical error—the third leading cause of death in the US. Bmj, 353, 2139.

Moore, W. (2016). Settlement reached in medication-error death at St. Charles. Web.

Wagner, C., Mannion, R., Hammer, A., Groene, O., Arah, O., Dersarkissian, M., & Sunol, R. (2014). The associations between organizational culture, organizational structure and quality management in European hospitals. International Journal For Quality In Health Care, 26(1), 74-80.

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