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Medication Errors in Family Practice, in Hospitals and after Discharge from the Hospital: An Ethical Analysis

Published online by Cambridge University Press:  01 January 2021

Peter A. Clark
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Extract

The issue of death due to medical errors is not new. We have all heard horror stories about patients dying in the hospital because of a drug mix-up or a surgery patient having the wrong limb amputated. Most people believed these stories were the exception to the rule until November 1999, when the Institute of Medicine (IOM) issued a report entitled To Err Is Human: Building A Safer Health System. This report focused on medical errors and patient safety in U.S. hospitals. The report indicated that as many as 44,000 to 98,000 people die each year in hospitals as a result of medical errors. These numbers suggest that more Americans are killed in U.S.hospitals every 6 months than died in the entire Vietnam War, and some have compared the alleged rate to fully loaded jumbo jets crashing every other day. This report was not without its critics.

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Article
Information
Journal of Law, Medicine & Ethics , Volume 32 , Issue 2 , Summer 2004 , pp. 349 - 357
Copyright
Copyright © American Society of Law, Medicine and Ethics 2004

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References

Kohn, L.T. Corrigan, J.M. Donaldson, M.S., eds., To Err Is Human: Building A Safer Health Care System. (Washington, D.C.: National Academy Press, 1999)Google Scholar
Hayward, R. Hofer, T.P., “Estimating Hospital Deaths Due To Medical Errors: Preventability Is In The Eye Of The Reviewer,” JAMA 286, no. 4 (2001): 415–420.CrossRefGoogle Scholar
McDonald, C.J. Weiner, M. Hui, S.L., “Deaths Due To Medical Errors Are Exaggerated In Institute of Medicine Report,” JAMA 284, no. 2 (2000): 93–95.CrossRefGoogle Scholar
Leape, L., “Institute of Medicine Medical Errors Figures Are Not Exaggerated,” JAMA 284, no. 2 (2000): 95–97.CrossRefGoogle Scholar
Migdail, K., Medical Errors: The Scope OF The Problem Fact Sheet, Publication No. AHRQ 0O-P037 (February 2000): 1–4, available at <http://www.ahrq.gov/qual/errback.htm> (last visited April 5, 2004).+(last+visited+April+5,+2004).>Google Scholar
Id. at 1.Google Scholar
Id. at 1–2.Google Scholar
Medical Malpractice Referral Network, “Medical Malpractice Lawyer,” at <http://www.medical-malpractice-lawyers-attorneys.com>, at 1.,+at+1.>Google Scholar
Editorial, “Errors That Kill Medical Patients,” New York Times, December 18, 2002, 23.Google Scholar
Dovey, S.M. Meyers, D.S. Phillips, R.L. et al. “A Preliminary Taxonomy Of Medical Errors In Family Practice,” Quality and Safety in Health Care 11 (2002): 233–238.CrossRefGoogle Scholar
Forster, A.J. Murff, H.J. Peterson, J. et al. , “The Incidence and Severity of Adverse Events Affecting Patients After Discharge from The Hospital,” Annals of Internal Medicine 138, no. 3 (2003): 161–168.CrossRefGoogle Scholar
Migdail, , supra note 5, at 1.Google Scholar
Id. at 2.Google Scholar
Kohn, , supra note 1, at 2.Google Scholar
Dovey, , supra note 10, at 233–238.Google Scholar
Lazarou, J. Pomeranz, B. Corey, P., “Incidence Of Adverse Drug Reactions In Hospitalized Patients,” JAMA 279, no. 15 (1998): 1200–1205.CrossRefGoogle Scholar
Editorial. “Medication and Prescription Errors,” Injuryboard.com (July 12, 2003), at <http://www.injuryboard.com/view.cfm/ID=545/REFID=8828>..>Google Scholar
Id.Google Scholar
Nordenberg, T., “Make No Mistake: Medical Errors Can Be Deadly Serious,” FDA Consumer Magazine (2000): 1–8, available at <http://www.fda.gov/fdac/features/2000/500_err.html>.CrossRef.>Google Scholar
Forster, , supra note 11, at 165.Google Scholar
Id. at 164–165.Google Scholar
Id. at 166.Google Scholar
Kohn, supra note 1.Google Scholar
Brennan, T., “The Institute of Medicine Report on Medical Errors: Could It Do Harm?” N. Eng. J. Med. 342, no. 15 (2000): 1123–1125.CrossRefGoogle Scholar
Oberg, A., “Protect Patients from Errors,”USA Today, January 27, 2003, 17A.Google Scholar
Leape, L., “Reporting of Adverse Events,” N. Eng. J. Med. 347, no. 20 (2002): 1633–1638; see also, Flowers, L. Riley, T., “State-Based Mandatory Reporting of Medical Errors: An Analysis of the Legal and Policy Issues.” (Portland, ME.: National Academy of State Health Policy, March 2001).CrossRefGoogle Scholar
Zwillich, T., “Senate Panel Approves Medical Error Bill,” Reuters Health (July 23, 2003), at <http://www.reutershealth.com/archive/2003/07/23/eline/links/200>..>Google Scholar
Nordenberg, , supra note 19, at 7.Google Scholar
Medical Malpractice Referral Network, supra note 8, at 2.Google Scholar
<Http://www.leapfroggroup.org/consumer_intro2.htm> (last visited April 5, 2004). See also Association of American Medical Colleges, Joint Committee of the Group On Resident Affairs and Organization of Resident Representatives, “Patient Safety and Graduate Medical Education” (Washington, D.C.: Association of American Medical Colleges, November 2002): 6.+(last+visited+April+5,+2004).+See+also+Association+of+American+Medical+Colleges,+Joint+Committee+of+the+Group+On+Resident+Affairs+and+Organization+of+Resident+Representatives,+“Patient+Safety+and+Graduate+Medical+Education”+(Washington,+D.C.:+Association+of+American+Medical+Colleges,+November+2002):+6.>Google Scholar
Medical Malpractice Referral Network, supra note 8, at 4.Google Scholar
Tokarski, C., “Computerized Order Entry Lowers Medication Errors in Children,” Pediatrics 112, no. 3, (2003): 506–509.Google Scholar
Piasecki, M., “Electronic Devices May Be a Cure for Rx Errors,” Austin Business Journal (April 17, 2000), at <http://austin.bizjournals.com/austin/stories/2000/04/17/focus4.html>..>Google Scholar
Prager, L. “Jury Blames Doctor’s Bad Penmanship For Patient’s Death,” AMNews (November 22–29, 1999): 1–4, at <http://www.ama-assn.org/sci-pubs/amnews/pick_99/pr121122.htm>..>Google Scholar
“Medical Mistakes,” Spiritual One (June 19, 2002) at <http://www.divinecipher.com/spiritualone/archives/00000215.html>..>Google Scholar
Blendon, R. DesRoches, C. Brodie, M. et al. , “Views of Practicing Physicians and the Public on Medical Errors,” N. Engl. J. Med. 347, no. 24 (2002): 1933–1940.CrossRefGoogle Scholar
Medical Malpractice Referral Network, supra note 8, at 2.Google Scholar
Association of American Medical Colleges, supra note 30, at 10.Google Scholar
Medical Malpractice Referral Network, supra note 8, at 6.Google Scholar
Migdail, , supra note 5, at 2.Google Scholar
There were 150 documented interventions recommended during the rounding process, 147 of which were accepted by the team. The most common interventions were (1) dosing-related changes and (2) recommendations to add a drug to therapy. See Kucukarslan, S. Peters, M. Mlynarek, M. et al. , “Pharmacists on Rounding Teams Reduce Preventable Adverse Drug Events in Hospital General Medicine Units,” Archives of Internal Medicine 163 (2003): 2014–2018.CrossRefGoogle Scholar
Forster, , supra note 11, at 166.Google Scholar
Brennan, , supra note 24, at 4–5.Google Scholar
Oberg, , supra note 25, at 17A.Google Scholar
Kohn, supra note 1.Google Scholar
American Medical Association Council on Ethical and Judicial Affairs, The Code of Medical Ethics (Chicago, IL.: American Medical Association, 1998): xv.Google Scholar
Thurman, A., “Institutional Responses to Medical Mistakes: Ethical and Legal Perspectives”, Kennedy Institute of Ethics Journal 2, no. 2 (2001): 147–156.CrossRefGoogle Scholar
Id. at 151.Google Scholar
Leape, , supra note 26, at 1635.Google Scholar
Id. at 152. Marshall Kapp provides an excellent survey of the available literature and studies, including the opposing arguments. See Kapp, M., “Medical Errors vs. Malpractice,” DePaul Journal of Health Care Law 1 (1997): 751–772; see also Kraman, S.S. Hamm, G., “Risk Management: Extreme Honesty May Be the Best Policy.” Annals of Internal Medicine 131 (1999): 963–967.Google Scholar
DeVita, M.A., “Honestly, Do We Need a Policy on Truth?” Kennedy Institute of Ethics Journal 2, no. 2 (2001): 157–164.CrossRefGoogle Scholar
Purtilo, R.B., “Conduct, Virtue, and Context in the Professional-Patient Relationship,” in Reich, W., ed., Encyclopedia of Bioethics, Rev. ed. (New York: Simon & Schuster and Prentice Hall: 1995): 2096.Google Scholar
Migdail, , supra note 5, at 1.Google Scholar
Brennan, , supra note 24, at 4.Google Scholar
Oberg, , supra note 25, at 17A.Google Scholar
Nordenberg, , supra note 19, at 6.Google Scholar
H.B. 0363, § 456.42, 2003 Leg. (Fla. 2003) (“An Act Relating to Drug Prescriptions”).Google Scholar