HSA 515
Katina4
health_care_law_learnscape_2_final_1.pdf
Health Care Law Learnscape 2: Medication Errors
Health Care Law Learnscape 2 v2.0 November 26, 2012 1
Medication Errors Introduction:
You are the hospital administrator and you’ve been presented with a negligence case stemming from an
incident in the main hospital pharmacy. You will interview staff members and work with the General
Counsel to analyze the four elements of negligence in order to determine the hospital’s liability:
1. Duty to care
2. Breach of duty
3. Injury
4. Causation (specifically foreseeability)
You will provide an analysis of the hospitals’ liability for each element to Bright Road Health System’s
General Counsel.
Characters:
1. Jeff Passmore, General Counsel at Bright Road Health System
2. Barry Longmore, Licensed Pharmacist at Bright Road
3. Tatiana Velasco, Pharmacy Technician at Bright Road
Locations:
1. Student’s Office
2. General Counsel’s Office
3. Hospital Hallway
4. Hospital Pharmacy
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Scene 1: Talk with Tatiana in the Hallway
In this opening scene, the Student is on the way to the Chief Counsel’s office and runs into the pharmacy
technician, Tatiana, who is upset over the new lawsuit that she is involved in.
Location Hospital Hallway
Scene setup Tatiana walks in from left and stops to address Student.
On-screen characters Tatiana Velasco
Off-screen characters
None
On-screen text: On your way to the Chief Counsel’s office, you run into Tatiana Velasco . . .
STUDENT Hi, Tatiana! How are you?
TATIANA (flustered, sad) Well, you’re about to find out. Are you on your way to see Jeff
Passmore?
STUDENT Yes. How did you know?
TATIANA I figured he might need your help with this new lawsuit. Unfortunately, I’m a part of it
because of something that happened in the pharmacy.
STUDENT OPTION 1 I’m sorry to hear that. Hopefully, I can help.
STUDENT OPTION 2 Do you want to talk about it?
Student can click on any of these options to proceed.
TATIANA It’s just one of those terrible things that happens, you know. And, I know it’s not
my fault, but I can’t help but feel . . . <starts to get emotional> I mean, it’s been
almost six months, but it still feels like yesterday. I hope you’ll be able to help
Jeff figure something out.
STUDENT What are you doing later? Do you want to grab lunch and talk more?
TATIANA I would, but I’m on duty in the pharmacy soon and won’t be able to have lunch
until two today. I appreciate it, but I guess this is just all part of the job, and I
have to get used to it. I can’t let things that are out of my control get me down.
That could affect how I perform today, and then . . . yeah, not good.
STUDENT OPTION 1 You’re right. How long have you been out of school? Not long, right?
STUDENT OPTION 2 Yes, try not to worry. We’ll get this figured out, Tatiana.
Student can choose either option to continue. Student must choose both eventually.
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TATIANA RESPONSE 1 No, not long at all. Just under a year. I get the feeling that I’m the freshman
around here. I just can’t get over the fact that if I had only done my part right,
then that little baby <gets choked up> I’m sorry. Here I go again! <Takes a
breath, shakes it off> I’m going to be strong. I have a few minutes before I start.
I think I’ll go and meditate a little in the staff lounge to relax myself.
Response 1 kicks the Student back to options.
TATIANA RESPONSE 2 I hear you. You’re very sweet. I’ll see you around, okay?
Response 2 allows the Student to proceed.
STUDENT Okay, Tatiana. Take care.
TATIANA You too.
Tatiana walks off, wiping her eyes.
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Scene 2: Meeting with Jeff Passmore, Chief Counsel
Next, the Student meets with Jeff Passmore, who lays out a high level overview of the lawsuit involving
Tatiana. The Student is given direction on who to talk to and how to help Jeff determine what the
hospital’s liability is.
Location Chief Counsel’s Office
Scene setup Jeff faces the Student from behind his desk.
On-screen characters Jeff Passmore
Off-screen characters None
On-screen text: Moments later, in the Chief Counsel’s office . . .
JEFF So, she was pretty upset, huh? I hope I didn’t make it worse. I can be a little too
cut and dry sometimes, especially when I’m overloaded. That’s where I can use
your help, actually.
STUDENT Sure. Can you tell me what happened?
JEFF Yes, although it’s a bit complex. You may want to take some notes.
The notepad icon is highlighted and an on-screen text bubble appears.
On-screen text: Remember to take notes as you go. These notes will be available throughout, and will
help you form your recommendation at the end.
Student is able to open the notepad and take notes during the rest of the scene with Jeff.
JEFF Okay. So, what we have here is a tragic case where it appears a medication error
in the pharmacy may have led to the death of an eight-week old infant.
STUDENT OPTION 1 I can see why Tatiana was so upset. She was working at the time?
STUDENT OPTION 2 So, how would you like me to help with this?
STUDENT OPTION 3 Was there an incident report filed?
Student can click on any of these options to proceed. Student must click all eventually.
JEFF RESPONSE 1 Yes, Tatiana was the one who actually prepared the medication for delivery to
the patient. Understandably, she’s a wreck over this.
Response 1 kicks the Student back to options.
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JEFF RESPONSE 2 As one of our best hospital administrators, I’d like you to help with gathering
the necessary information that we’ll need to determine Bright Road’s liability in
this case. Once you’ve had a chance to talk to the parties involved, we can meet
again and see where to go from there.
Response 2 kicks the Student back to options.
JEFF RESPONSE 3 Yes, it’s standard procedure, but I’m afraid it doesn’t tell us too much. It
documents that the medicine went from point A, the pharmacy, to point B,
administration to the patient in the NICU (nick-you), but I know there was a lot
more going on that day than stated in the report and those details can help
shed light on the situation.
Response 3 allows the Student to proceed.
STUDENT Can I talk with the pharmacist that was on duty that day?
JEFF Yes. His name is Barry Longmore. I will send you his contact info by email.
Between him and Tatiana, you should be able to get a good handle on what
happened.
STUDENT OPTION 1 Will Tatiana lose her job because of this?
STUDENT OPTION 2 So, what type of information do I need to gather for this suit?
Student can click on any option to proceed. Student must choose both eventually.
JEFF RESPONSE 1 Let’s not get too far ahead of ourselves. Like I said, I think there’s more to the
story than we’re getting in the report.
Response 1 kicks the Student back to options.
JEFF RESPONSE 2 First, let’s determine if a duty to care was established, and then whether the
duty was breached or not. We know, unfortunately, that the patient was fatally
injured. The question is causation. We’ll need to determine that with particular
attention on foreseeability.
Response 2 allows the Student to proceed.
STUDENT OPTION 1 Can you refresh my memory on causation?
STUDENT OPTION 2 What is foreseeability?
STUDENT OPTION 3 What about hospital and pharmacy policies and procedures? Should I look into
those?
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Student can click on any option to proceed. Student must choose booth eventually.
JEFF RESPONSE 1 Causation requires that there be a reasonable, close, and causal connection or
relationship between the defendant’s negligent conduct and the resulting
damages suffered by the plaintiff. In other words, the defendant’s negligence
must be a substantial factor causing the injury. Proximate cause refers to the
relationship between a breached duty and the injury. The breach of duty must
be the proximate cause of the resulting injury.
Response 1 kicks the Student back to options.
JEFF RESPONSE 2 Foreseeability is a little tricky. It is the reasonable anticipation that harm or
injury is likely to result from a commission or omission of an act. The test for
foreseeability is whether someone with ordinary prudence and intelligence
should have anticipated the danger to others caused by his or her negligent act.
The test for foreseeability is not what the wrongdoer believed would occur;
instead, it is whether the wrongdoer ought to have reasonably foreseen that the
event in question, or some similar event, would occur.
Response 2 kicks the Student back to options.
JEFF RESPONSE 3 Yes, you should definitely look into the hospital’s policies and procedures, to see
if they were lacking in this situation, or if they were sufficient.
Response 3 allows the Student to proceed.
STUDENT Sounds good. Can I call if I run into any roadblocks?
JEFF Of course.
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Scene 3: Discussion with Barry Longmore, Pharmacist
The student meets with Barry Longmore, the pharmacist who was on duty the day of the incident. Barry
provides important first-hand information about the incident and insight into causation, foreseeability,
and hospital and pharmacy policies and procedures.
Location Student’s Office
Scene setup Barry sits in the left chair on the other side of the Student’s desk
On-screen characters Barry Longmore
Off-screen characters None
On-screen text: Meeting with pharmacist, Barry Longmore . . .
STUDENT Thank you for taking the time to talk with me today, Barry.
BARRY Absolutely. I want to get to the bottom of this also. What should we start with?
STUDENT OPTION 1 [BRANCHING 1] Why don’t you relate what happened that day?
STUDENT OPTION 2 [BRANCHING 2] Can you talk about the policies and procedures that were in
place at the time?
STUDENT OPTION 3 [BRANCHING 3] Is it safe to say the medication error led to the infant’s death?
Student can click on any of the three options to continue, but must choose all eventually.
BRANCHING 1
BARRY RESPONSE B1 Well, I remember it was a crazy day. But, unfortunately, some things lined up at
just the right time, or more like the wrong time, and this terrible mistake took
place.
STUDENT OPTION 1 Can you start at the beginning?
STUDENT OPTION 2 What were some of those factors?
STUDENT OPTION 3 How did the medication leave the pharmacy if it was wrong? Isn’t there a
system of checks and balances?
Student can choose any option to proceed.
BARRY RESPONSE 1 Sure. The order came through for a simple IV antibiotic for an eight-week old
baby. One of the pharmacy technicians received it, and she began work on it. It
was Tatiana Velasco, a very smart and capable pharmacy tech, even though
she’s fairly new. But, things get very hectic very quickly at the hospital pharmacy
with stat orders and emergency orders always being called in. So, when I picked
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up the IV bag Tatiana prepared to check it, I thought it was a bit too cloudy.
Something seemed wrong. I was about to ask Tatiana about it when I got pulled
away.
Response 1 kicks the Student back to Branching 1 options.
BARRY RESPONSE 2 Well, for one, we had two new pharmacy techs on duty that day. Anyway, the
second pharmacy technician who actually isn’t up to speed like Tatiana,
required a lot of my attention that morning. So, she pulled me away for an
urgent question right when I was about to talk to Tatiana about the IV bag for
the infant. This was my responsibility, no doubt. I think the other pharmacist
was on break at that moment; otherwise she would’ve handled the question.
Meanwhile, the IV bag had been picked up and delivered to NICU. It just slipped
my mind when I was frantically called to the outer pharmacy to prepare an
emergency stat drug for the emergency department. I wasn’t aware the IV bag
had been released from the pharmacy. I didn’t know it was gone until later, and
by then, it was already too late.
Response 2 kicks the Student back to Branching 1 options.
BARRY RESPONSE 3 That’s just it. It should never have left the pharmacy. I specifically set it down
“next to” the IV Medication Outbox, not “in” the Outbox in the IV room, which
meant I still needed to check it. When I was called out for that emergency drug
order, the second pharmacist, who returned from break, was asked for the IV
antibiotic from a nurse from NICU. Maybe the pharmacist thought it had fallen
out of the Outbox, but she gave the medication to the nurse who brought it to
the NICU where it was administered to the infant.
Response 3 kicks the Student back to Main Branching options.
BRANCHING 2
BARRY RESPONSE B2 Yes, we had policies and procedures in place, but obviously they could use
improvement.
STUDENT OPTION 1 Can you talk about the procedure for checking meds before they leave the
pharmacy?
STUDENT OPTION 2 How do you think the procedure could be improved to make sure meds don’t
leave the pharmacy, unchecked or without approval of a licensed pharmacist?
Student must choose both options to proceed.
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BARRY RESPONSE 1 Sure. All orders filled by a pharmacy technician must be double checked and
initialed in a “drugs dispensed log book” by a pharmacist before they leave the
pharmacy. With the exception of unlicensed pharmacists, pharmacists don’t
need their own orders checked.
Response 1 kicks the Student back to Branching 2 options.
BARRY RESPONSE 2 Well, we’ve been relying on the Medication Outbox as an indicator that meds in
the box have been checked and are ready for pick-up and dispensing. But, as
you can see, that’s not good enough. I think we should remind pharmacists not
to initial questionable med orders or place them near the outbox before their
concerns are addressed. When someone takes the medication out of the
Outbox to pass on for delivery, as an extra precaution, they could double-check
the logbook to verify the initials of a licensed pharmacist are present.
Response 2 kicks the Student back to Main Branching options.
BRANCHING 3
BARRY RESPONSE B3 Unfortunately, yes. I had a feeling that the mixture was too high. It was too
concentrated.
STUDENT OPTION 1 So, the dose that was given to the infant of the IV antibiotic from the pharmacy
is what led to the child’s death?
STUDENT OPTION 2 Would the infant have survived if given the correct dosage of the antibiotic?
Student can click on either option to proceed.
BARRY RESPONSE 1 Yes, it’s clear that that was the cause of death. It’s really a sad case.
Response 1 kicks the Student back to Branching 3 options.
BARRY RESPONSE 2 I’m not sure of the exact medical condition of the child. I don’t know how
serious his infection was. All I know is that, if the medication had been right, it
would not have led to the infant’s death.
Response 2 allows the Student to proceed.
STUDENT Was there a way to know this before the medication left the pharmacy?
BARRY Well, yes. That’s why I was going to check it with Tatiana before it left. I just
wish I had had a chance to get to the IV bag and that the other pharmacist
hadn’t assumed it was ready to go. None of this would’ve happened.
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STUDENT Barry, I appreciate your honestly and helpfulness. I know this isn’t easy to talk
about.
BARRY It is hard, but my heart really goes out to Tatiana, and of course to those poor
parents. Let me know if you need anything else, and I’ll be glad to help.
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Scene 4: Meeting Tatiana in the Pharmacy
Next, the student meets with Tatiana, but the meeting does not go well. Discouraged, the Student calls
on Jeff for guidance.
Location Hospital Pharmacy
Scene setup Student faces Tatiana on the other side of the counter.
On-screen characters Tatiana Velasco, Jeff Passmore (on video call)
Off-screen characters None
On-screen text: You meet Tatiana at the Pharmacy later . . .
STUDENT Are you sure this is a good time to talk? It seems busy back there.
TATIANA It’s always busy here. No, this is fine, really. I’m on lunch break for another twenty
minutes anyway. They can handle things without me, that’s for sure.
STUDENT Thanks, Tatiana. Just let me know if you need to go, though.
TATIANA I will. But, it will most likely be because I become an emotional wreck again. I’m sorry. I
know it’s unprofessional, and I keep telling myself mistakes and accidents are going to
happen all of the time. It’s just difficult, you know?
STUDENT OPTION 1 [BRANCHING 1] It’s understandable, really. I just wanted to hear your side of
the story.
STUDENT OPTION 2 [BRANCHING 2] I certainly don’t want to make this any harder than it is. Can we
talk for a moment about foreseeability?
Student can click on either option to proceed, but must choose both eventually.
BRANCHING 1
TATIANA RESPONSE 1 My side? Why? Am I being sued personally? Jeff didn’t say anything about that. I
can’t believe this.
**STUDENT OPTION 1 (correct) No, I just meant that I’m gathering facts from all parties.
STUDENT OPTION 2 It’s my job to see who is liable here.
Student can choose either option to proceed.
TATIANA Well, I pretty much told Jeff everything already. The order for the antibiotic
came through and I filled it. I put it in the review basket for the pharmacist to
review, and that’s the last I saw of it. It was busy that day, as always. You have
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orders coming from all directions and sometimes you get interrupted for
emergency orders in the middle of the ones you’re working on. I did my part in
the system we have here. I didn’t know this was going to happen, believe me.
Response kicks the Student back to branching options.
BRANCHING 2
TATIANA RESPONSE 2 What do you mean by foreseeability? I don’t understand.
STUDENT OPTION 1 Foreseeability deals with whether you should’ve known the outcome would
happen before it happened.
STUDENT OPTION 2 I’m trying to figure this out myself, whether it was Barry Longmore who
should’ve anticipated this tragedy and not you.
Student can choose either option to proceed.
TATIANA RESPONSE 1 Really? I mean, if you ask me now, then I’d say yes. But, it wasn’t supposed to
happen this way. Even a small mistake can lead to a patient’s death. Really, I just
don’t understand.
Response 1 kicks the Student back to options.
TATIANA RESPONSE 2 You keep implying that I’m the one to blame here. That if I had just done my job
right, then that little baby would be alive right now. If that’s what you want to
hear, then fine, yes. You’re right. I should’ve mixed the med right. I should’ve
asked if I wasn’t sure. But, I wasn’t thinking right, at the time, and I’m sorry. I
really am. <gets emotional> I need to go.
STUDENT I’m sorry, Tatiana. I didn’t mean to come across that way.
TATIANA Please. I can’t go back on shift like this. I need some time alone. Excuse me.
Tatiana exits.
NOTE: The Student’s phone appears with an incoming call from Jeff Passmore’s number. The Student can
click to answer, and a video call ensues.
JEFF (on phone) Hi! Just checking in to see how things are going.
STUDENT Good timing, Jeff. My talk with Tatiana didn’t go as well as my talk with Barry
Longmore. She’s still very emotional.
JEFF (on phone) I can see how that might be the case. She is much newer at all this than he is.
So, what is she saying?
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**STUDENT OPTION 1 She’s so wrapped up in blaming herself, she thinks we’re trying to do the same.
STUDENT OPTION 2 I think I pushed too hard on foreseeability, and now she’s worried that she’ll be
held personally liable for what happened.
Student can choose either answer to continue.
JEFF Did you let her know that our main concern is with hospital liability? As an employee of
the hospital, she won’t be held liable on her own. Also, you have to be careful when you
talk about foreseeability that you don’t paint people in the wrong light. This appears to
be her first mistake. It’s not like she’s had multiple errors and should be let go or
punished for incompetency.
STUDENT OPTION 1 How do I get her to see that?
STUDENT OPTION 2 What can we do to help her with the guilt she’s feeling?
Student must choose both options before they can continue.
JEFF RESPONSE 1 First, I would talk to her in a more private environment, like your office with the
door closed. And, you might want to consider bringing Barry in on the meeting,
too. He’s been through this before, and his presence might help set her at ease.
Response 1 kicks the Student back to options.
JEFF RESPONSE 2 Maybe, we can recommend that she see the staff counselor at the hospital.
Sometimes it helps to talk these situations out with a professional, to put things
in perspective.
Response 2 allows the Student to proceed.
STUDENT Maybe you should be the one to suggest counseling. She and I aren’t exactly
communicating well right now.
JEFF Okay, but don’t give up. You can do this.
STUDENT Thanks, Jeff.
JEFF You’re doing fine. Just let me know where you need my help.
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Scene 5: Meeting with Tatiana and Barry Longmore
The student meets with both Tatiana and Barry Longmore, to determine foreseeability and discuss the
breakdown of pharmacy procedure.
Location Student’s Office
Scene setup Tatiana and Barry sit in both chairs opposite the Student’s desk.
On-screen characters Tatiana Velasco, Barry Longmore
Off-screen characters None
On-screen text: Next you meet with Tatiana and Barry . . .
STUDENT Now that we’re all together, I want us to get to the bottom of what happened.
TATIANA First, I want to apologize, again, for getting so emotional in our last discussion.
STUDENT I understand. It’s not an easy subject. I appreciate you agreeing to meet with Barry here,
too. I think his experience can be a big help in this situation.
BARRY Well, I unfortunately have had more experience in this sort of thing. Comes with the
territory.
STUDENT OPTION 1 Barry, can you share some insight on this situation?
STUDENT OPTION 2 Can we discuss personal liability versus hospital liability?
STUDENT OPTION 3 Can we talk a little more about foreseeability?
Student may click on any option to continue, but must choose all eventually.
BARRY RESPONSE 1 Well, I think it’s important to know that this is a situation that reflects more of a
breakdown in hospital procedure than the particular negligence of any one
person. The whole reason we have a process where the pharmacist checks the
orders filled by technicians is to avoid situations like these, because technicians
aren’t licensed pharmacists. And, remember, the IV antibiotic was released from
the pharmacy before I was able to properly check it.
TATIANA RESPONSE 1 So, you’re saying then, that because the order went out before you had a
chance to check it, then it wasn’t really my fault?
BARRY RESPONSE 1 Yes, it’s like asking a junior bomb squad tech to disarm a bomb without even the
guidance of a senior technician.
This response kicks the Student back to options.
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BARRY RESPONSE 2 Sure. It ties in to what I was saying. There were several factors involved, here.
Yes, the order was mixed incorrectly. And, I should not have left it so close to
the Outbox, leading to the other pharmacist handing it out prematurely. This all
points to the fact that we need more safety checks in place, not just better
procedures. Also, since we’re all employees of the hospital, I’m pretty certain
that we are covered under the hospital’s insurance policy.
Response 2 kicks the Student back to options.
BARRY RESPONSE 3 Sure. I think that, if I had had a chance to check the med order, I would have
seen that the mixture was off, and I would’ve had it corrected. It would’ve been
foreseeable that serious injury and even death would’ve resulted by
administering it. So, yes, we should’ve foreseen this. But, as I said, we didn’t
even have a chance to follow normal procedures because the other pharmacist
took the IV bag and handed it out for delivery.
TATIANA RESPONSE 3 So, really, it was the other pharmacist’s fault, right?
Response 3 allows the Student to proceed.
STUDENT Remember, we’re not trying to place fault with one person.
BARRY Right, I put the bag close to the Outbox. Again, this could be considered my fault
for creating confusion by doing that. Looking back, I should’ve just placed it back
in the review pile if I didn’t have time to finish checking it at the moment.
STUDENT OPTION 1 You mentioned initialing med orders on approval. Would this solve the
problem?
STUDENT OPTION 2 Are there other procedural changes that should be made?
Student must choose each option to proceed.
BARRY RESPONSE 1 Well, we do initial each technician’s work. It is our current procedure. My only
concern is that, the medication log should be checked to be sure a licensed
pharmacist verifies the technician’s work before it is sent to the patient unit for
administration. In this case I had not initialed the log because I had some
questions about the proper dilution of the antibiotic. Unfortunately, another
pharmacist dispensed the antibiotic without checking to see if the technician’s
work was verified.
TATIANA RESPONSE 1 Yes, but the procedure… well it broke down. The drug wasn’t in the outbox. It
was beside it and the log wasn’t signed.
Response 1 kicks the Student back to options.
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BARRY RESPONSE 2 Well, we’d need whoever is taking the order from the Outbox to make sure that
the medications have been verified. It doesn’t do any good having a verification
log there if no one is checking it. Also, we need to identify a location more
distant from the outbox where we can place questionable medication
preparations. This way they won’t be mistakenly dispensed.
STUDENT But, if these extra steps will help reduce the risk of tragic errors like these, don’t
you think it’s worth it?
BARRY Sure, I think it’s worth it. But, unfortunately, we can’t avoid mistakes happening
within any system. I mean, people are human, after all, and sometimes, like in
this situation, things align badly, no matter how good your system is.
TATIANA I agree. I’m learning this the hard way, really. But, I also think that having the
best system in place will make a difference in lowering medication errors. And,
won’t it help in reducing the liability of the hospital, too?
STUDENT Well, I’m not too sure about that. But, I agree having the best system in place is
ideal. Thank you both, for your time and help with this. I really appreciate it.
BARRY Sure thing.
TATIANA I appreciate you giving me a little time to work through this. The counselor Jeff
recommended also helped me be in a much better state of mind for our
conversation today. It’s a learning process, but I’m getting there; trying, like she
said, to learn from my mistakes and to focus more on the good, on the many
lives we’re saving each day.
BARRY Sounds like a good plan.
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Scene 6: Review and Analysis with Mentor
In this scene, the Student meets with Jeff to review the details of the medication error case. Jeff will ask
questions to help the Student analyze and prepare for writing a recommendation on the hospital’s
liability.
Location Chief Counsel’s Office
Scene setup Student faces Jeff who sits at his desk.
On-screen characters Jeff Passmore
Off-screen characters None
On-screen text: Later, you go over the details of the case with Jeff . . .
JEFF I heard from Tatiana that your last meeting went well. I’m glad to hear that.
STUDENT Yes. She seems to be in a much better place now.
JEFF So, are you ready to help me make a decision on the hospital’s liability in this
case?
STUDENT I think so. But, can we go over some of the details first? I want to be sure.
JEFF Certainly. These things are trickier than they seem sometimes.
STUDENT OPTION 1 [BRANCHING 1] So, duty to care was established and was clearly breached.
STUDENT OPTION 2 [BRANCHING 2] We know that the worst possible injury occurred, death. And
we know that the medication error caused it.
STUDENT OPTION 3 [BRANCHING 3] Foreseeability is still a little foggy right now.
Student can click on any option to proceed. Student must choose all eventually.
BRANCHING 1
JEFF RESPONSE B1 Okay. On what grounds?
STUDENT OPTION 1 The patient was under the care of the hospital.
STUDENT OPTION 2 The hospital had a duty to help the patient, not bring further harm.
STUDENT OPTION 3 The incorrect IV antibiotic dose leading to the infant’s death is clear evidence
that the duty to care was breached.
Student can choose any option to proceed.
JEFF RESPONSE 1 Right! What else?
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Response 1 kicks the Student back to Branching 1 options.
JEFF RESPONSE 2 Yes, a duty to care carries with it a corresponding responsibility to provide care
in an acceptable manner in line with the current standard of care.
Response 2 kicks the Student back to Branching 1 options.
JEFF RESPONSE 3 Okay, but it’s important to know that just because an injury occurred is not
always sufficient grounds for imposing liability. It could’ve been an unrelated
accident, something out of the hands of the hospital, or an “act of God.” But,
like you said, in this case, the employees of the hospital clearly deviated from
the practice of competent members of their profession.
Response 3 kicks the Student back to Main Branching options.
BRANCHING 2
JEFF RESPONSE B2 Okay, you’ve established the injury. Are you clear on causation? How would an
expert testify to this?
STUDENT OPTION 1 We know that the IV antibiotic was filled at the pharmacy and administered in
the NICU to the infant. The death of the infant was due to an overdose and
nothing else. The incorrect medication could’ve caused it.
STUDENT OPTION 2 In this situation, it would be easy for an expert to agree with the finding that the
death of the infant was caused by the improper medication filled at the
pharmacy.
Student must choose both options to proceed.
JEFF RESPONSE 1 Good. Remember, causation requires that there be a reasonable, close and
causal connection between the defendant’s negligent conduct and the resulting
damages suffered by the plaintiff. We can clearly see that here.
Response 1 kicks the Student back to Branching 2 options.
JEFF RESPONSE 2 I think you’re right. Just like in the Shegog vs. Zabrecky case where a patient
died due to administration of a statutorily prohibited drug, since there was no
other medicine introduced, an expert would surely testify that injury resulted
from the improper medication being administered.
Response 2 kicks the Student back to Main Branching options.
BRANCHING 3
JEFF RESPONSE B3 What are your concerns about foreseeability?
Health Care Law Learnscape 2: Medication Errors
Health Care Law Learnscape 2 v2.0 November 26, 2012 19
STUDENT OPTION 1 The pharmacist says that he thought the medication might be wrong, but he
never had a chance to check it. Does this make him liable?
STUDENT OPTION 2 Tatiana, the pharmacy tech, didn’t foresee the injury. She didn’t know she had
mixed the medication wrongly.
STUDENT OPTION 3 If foreseeability deals with whether a competent employee should’ve known
the injury would result, then is the incompetent person at fault and liable, not
the hospital?
Student can click on any option to proceed.
JEFF RESPONSE 1 Remember, foreseeability is just a part of the liability equation. Just because the
pharmacist could have foreseen the death of the child, doesn’t mean he’s liable.
All the elements of negligence must be established, which appears they have
been in this unfortunate incident. The fact that the pharmacist didn’t have a
chance to check the medication may be understandable. However, it does not
mitigate the results of human errors, in this case, death. Juries do not forgive
human errors. Further, the fact that the pharmacist was busy is no defense in
this case for him or the hospital.
Response 1 kicks the Student back to Branching 3 options.
JEFF RESPONSE 2 I understand that. And that’s what makes this difficult. Mistakes happen, but
they happen much less with highly competent people in place.
Response 2 kicks the Student back to Branching 3 options.
JEFF RESPONSE 3 No, the hospital is liable for its employees’ negligence. The hospital is
responsible for providing competent and well-trained staff to deliver the highest
standard of care to their patients. In the end, any employee of the hospital may
make a mistake, but it is the hospital that will be held at fault for an employee’s
negligence. This is true regardless of competency issues related to training or
supervision or just plain workload or distraction issues.
Response 3 allows the Student to proceed.
STUDENT Tatiana seems very competent, though. I think this was her first major error.
JEFF Right. I’m not saying anything personal about Tatiana. She did her job as best as
she knew how. The system that the pharmacy had in place was not upheld, or it
was lacking, and that’s another reason why the hospital could be found at fault.
The hospital must have the right policies and procedures in place, to provide
safe and acceptable care.
Health Care Law Learnscape 2: Medication Errors
Health Care Law Learnscape 2 v2.0 November 26, 2012 20
STUDENT I got a couple of recommendations on how to fix their policies and procedures.
Will this make the hospital immune from liability in the future?
JEFF It will definitely help to have better practices in place. It’s just that no system is
immune from human error, unfortunately. Mistakes happen, even in the best
hospitals. Bad circumstances line up sometimes. It’s an unfortunate part of the
business, but does not excuse the hospital from liability. The mother placed her
trust in the hospital and, whether intentional or not, that trust was breached.
STUDENT That makes sense. I think I’m ready to make my recommendation now.
JEFF Great. Can you write it up in and email it to me later, so I can go over it
carefully?
STUDENT Definitely. Thanks for the opportunity, Jeff. I’ve learned a lot on this one.
JEFF Thank you for all your hard work. I look forward to your email!
Health Care Law Learnscape 2: Medication Errors
Health Care Law Learnscape 2 v2.0 November 26, 2012 21
Scene 7: Making Your Recommendation
In this scene, the Student will write an email to Jeff Passmore with a recommendation on the hospital’s
liability in this medication error case. The recommendation will include details from the previous
conversations to support the Student’s position.
Location Student’s Office
Scene setup Student is sitting at their desk.
On-screen characters None
Off-screen characters None
On-screen text: In the body of the email below, type your recommendation to the Chief Counsel. Don’t
forget, you can use the notes you’ve taken throughout your interviews. Be sure to use details and cover
breach of duty, verification of injury, causation, and foreseeability in determining liability in this case.
To: Jeff Passmore, Chief Counsel, Bright Road
Re: CONFIDENTIAL: Recommendation on medication error case
Body of
Email:
NOTE: Student will be able to fill in their recommendation here.
NOTE: The student will be given an option to “Submit” the email after writing the recommendation. After
the student submits the email, the computer screen fades to the previous view of the student’s office.
On-screen text: Well done! Your recommendation to Jeff Passmore has been sent!
FADE OUT.
End of Learnscape 2
