Lessons from Colorado

Lessons from Colorado

Introduction

There has been a lot of debate surrounding the issues related to the medical errors in the health care systems. The research into the rate of these adverse events and their affects on the population along with the medical staff has revealed that these errors stem from a number of factors that can be easily controlled. These factors can emerge in any processes of the health care system but they have huge impact on the overall performance and dependability of the system.

These events can have consequences that can affect the patient at varying levels from severely paralyzing them or even take their lives. However, it is important to realize that any task that involves the human factor has a certain failure rate because humans are not perfect beings. A large majority of these medical errors are caused due to the latent factors that are present in the current systems that are being practiced in the hospitals.

This essay analyzes the 14 lessons that were studied by Smetzer after analyzing the medical error that was committed by the staff at the St. Anthony Hospital in the North outside of Denver (Smetzer 1998, 49-52). Two of these 14 issues have been discussed in greater detail with a discussion of the current research that has been carried out over the years to improve the environment to overcome the challenges posed by the issues.

Discussion

Insufficient drug information

The inability of the medical staff especially nurses to the information pertaining to the drug that needs to be administered for a patient is attributed to be among the leading causes of the medical errors. In the Colorado medical case, the mother of the newly born had a history of Syphilis. The doctors were facing a tough situation due to the language barrier and decided to treat the newly born for Syphilis to protect the child from future complications. However, during the drug that was chosen to treat the newly born was rarely used. The pharmacist was unfamiliar with the use and the dosage of the drug for newly born.

The qualified staff was not available and the on-duty replacement pharmacist has little information about the drug. However, the nurse consulted the recommendation's that were provided by the health department along with the documentations of the Drug Facts and Comparisons. While she was consulting these documents, she might have been overwhelmed with the information that she received. She committed one of the basic errors in medicine, the “look but fail to see” error (Green 2004). She read the dosage that was listed in these medical publications but erroneously misread them completely. The documents recommended a dosage of 50,000 units/kg, which was misread and misunderstood to be 500,000 units/kg. This difference in the drug quantity became the reasons of the death of the newly born.

The “look but fail to see” causes its victim to directly look at a sign for example the dosage in this case but fail to see in retrospection, what was actually ...