31820 Is it Criminal to Be Human? A Case Study

Course overview

Discussion of a care scenario that resulted in a patient death, including how different stakeholders have been or may be impacted, the factors surrounding the incident and how those factors may have contributed to the mistake, and the impact that criminalizing adverse events may have on staff, patients, and healthcare systems. Adverse drug events (ADEs) are one of the most common preventable adverse events in all care settings, and almost 5% of patients in the hospital experience an ADE, making them one of the most common types of errors in the inpatient setting. There are multiple steps during the medication prescription and administration process during which an error may occur, as well as multiple factors that may play a role in safe medication administration. While the advent of the electronic health record and medication dispensing systems may help to prevent errors, they continue to happen in healthcare settings, causing patient harm and even death. This program presents a case scenario where a medication error resulted in patient death, and discusses factors that may contribute to fatal errors involving a patient, as well as how both staff and system errors can be implicated in and impacted by events that result in patient harm or death.