Med Error Leads to Change in L&D Policy

05/14/24 • 6 min

A 30-year-old woman experiencing her first pregnancy, presented to the Labor and Delivery unit. She was given the wrong drug and required an emergent C-section. The “five rights” of medication administration focuses on individual factors and not necessarily on system flaws. Many organizations are also promoting just culture, which encourages reporting near-misses and patient safety events, and focuses on psychological safety and promoting a non-punitive reporting culture.

Previous Episode

Incidental Lung Nodule Overlooked, No Follow-up, Fatal Cancer Advances

A patient was imaged for abdominal pain, but the radiologist saw and reported an incidental finding of a nodule on the lower lung that was not pursued or revealed to the patient for 2 years. The cancer had metastasized, and the patient died from lung cancer 18 months later.

Next Episode

A Pending Test at Discharge and a Return with Sepsis

A 68-year-old male was admitted to the hospital after falling on ice and feeling short of breath. Two days after discharge, the patient arrived by ambulance at another hospital in septic shock. The patient filed a claim against the hospital, alleging that the failure to communicate a critical lab result required readmission and several weeks of follow-up treatment.