Discussion (1-2)

Summary of Case Study

M has been using a purple Seretide inhaler to control his asthma attacks. However, when his family moved to a new town, he ran out of his inhaler. He had to visit a new general practitioner who mistakenly gave him a new prescription, Serevent. The general practitioner had given M a wrong prescription, which was meant for another kind of asthma. M died later from the effects of the wrong inhaler. The general practitioner admitted to having made a mistake caused by similarities in the names of the two inhalers (“AvMA - M’s story,” 2020).

The medical error in this case study is look-alike drug names. Instead of prescribing Seretide, the general practitioner prescribed Serevent, which is a look-alike to Seretide. Among the six IOM domains, safe, patient-centered, and effective, apply to this case study (“Six Domains of Health Care Quality,” 2020). The new general practitioner did not offer safe care to M, which led to his death. Besides, the general practitioner did not give M his drug of preference, thus lacking patient-centeredness. Although Serevent is an asthma medication, it was not effective for M; he did not benefit from it.

The NPSG goals that apply to the case study are “use medicines safely and identify patient safety risk.” “Use medications safely-”the general practitioner gave the wrong information about M’s inhaler, failed to compare M’s former inhaler to the new one to ensure it was the right one, and failed to arrange for M’s follow up (“Jointcommission.org,” 2020). “Identify patient safety risk-” the general practitioner did not identify the harms the new inhaler might cause M.

How the Medical Error could have Been Prevented

The general practitioner could have confirmed with M’s mother that the drug’s name prescribed was the right one before M’s mother purchased it. Additionally, the general practitioner would have organized a follow up on M's condition after using the new inhaler. M’s mother would have brought with her the Seredite to the visit (“20 Tips To Help Prevent Medical Errors: Patient Fact Sheet,” 2020).

References

20 Tips To Help Prevent Medical Errors: Patient Fact Sheet. Ahrq.gov. (2020). Retrieved 3 December 2020, from https://www.ahrq.gov/questions/resources/20-tips.html.

AvMA - M’s story. AvMA. (2020). Retrieved 3 December 2020, from https://www.avma.org.uk/patient-stories/case-studies/ms-story/.

Jointcommission.org. (2020). Retrieved 3 December 2020, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2020/simplified_2020-hap-npsgs-eff-july-final.pdf.

Six Domains of Health Care Quality. Ahrq.gov. (2020). Retrieved 3 December 2020, from https://www.ahrq.gov/talkingquality/measures/six-domains.html.