Real World Case

According to an article published in the News-Tribune, a 39-year-woman, who was being treated for breast cancer, died as a result of receiving the wrong dosage of cyclophosphamide (a cancer-fighting agent) and an overdose of another drug meant to keep her from suffering side effects. This happened at a reputable facility that specializes in the treatment of cancer.

At least a dozen doctors, nurses, and pharmacists missed the medication error for four days. Her husband reported that she suffered tremendously as the lining of her intestine was shed, resulting in her literally vomiting sheets of tissue. The doctors had reassured the patient and her husband that all was normal. Her heart failed after receiving four times the recommended amount of medication.

An autopsy revealed no visible signs of cancer in her body, which indicated that the treatment had worked. Another woman died of a similar mistake two days earlier. Human error was felt the only possible explanation, according to the treatment center. Incorrect doses of medication through either dispensing error, administration error, or prescription error can be deadly. Moreover, many adverse events go unreported.

Discussion Questions

Instructions: Answer the following questions.

1. What type of event is this? Provide reasons to support your answer.

2. Hospitals perform several types of patient care reviews, usually through a committee. What type of review(s) would be done on this case? What is the process used to identify the cause of this death, identify who needs to be involved in the investigation, and what tools should be used to analyze the situation?

3. Discuss what kinds of changes are likely to result in an improved system for treating patients using toxic medications.