Medication errors: ethical implications

Errors in health care are receiving much attention today, although committing such errors is not a new phenomenon. Nurses are taught procedures so that they are less likely to make mistakes. Yet nurses do make errors. Although many types of errors can and do occur in the health care setting, this article focuses on a discussion of medication errors and related ethical implications. Several ethical issues may arise as a result of medication errors: harm to patients, whether to disclose the error, erosion of trust, and impact on quality care. Nurses' appropriate ethical responses to medication errors need to be supported. Changing the health care system will help nurses to promote patient welfare, lessen the chance of harm, and reduce the likelihood of medication errors occurring.     

The three most common errors in family nursing: how to avoid or sidestep

In this article, the authors offer what they believe to be the three most common errors or mistakes in relational family nursing practice. Each error is described, followed by practical suggestions on how the mistake or error can be avoided. A clinical case vignette for each error is also given, with useful ideas of how the mistakes could have been avoided or sidestepped. By sidestepping and avoiding the most prevalent mistakes, nurses can not only sustain but also improve their nursing care of families and thus prevent unnecessary anguish and suffering of family members and possible shame, guilt, or embarrassment on the part of the nurse.     

Commitment to health: a shared ethical bond between professions

It is commonly assumed that Codes of Ethics are supported by concrete ethical principles, that adherence to Codes of Ethics guarantees ethical behaviour and that there is widespread agreement about ethical standards. Each of these assumptions is false. Codes of Ethics are inevitably open to wide interpretation, and it is impossible to demonstrate absolute moral standards. Health and social care workers should not adhere to unexplained 'ethical principles' insufficient to guide practical decision making. Anyone who recognises that all human actions potentially have ethical content may choose to make an ethical commitment. In order to work for health, health workers ought to commit to a substantial theory of health. One such theory--the foundations theory of health--is briefly explained and illustrated. The foundations theory can form a shared ethical bond between health and social care professionals, since both professions regularly strive to achieve foundational health for their patients and clients.     

Commitment to health: a shared ethical bond between professions

It is commonly assumed that Codes of Ethics are supported by concrete ethical principles, that adherence to Codes of Ethics guarantees ethical behaviour and that there is widespread agreement about ethical standards. Each of these assumptions is false. Codes of Ethics are inevitably open to wide interpretation, and it is impossible to demonstrate absolute moral standards. Health and social care workers should not adhere to unexplained 'ethical principles' insufficient to guide practical decision making. Anyone who recognises that all human actions potentially have ethical content may choose to make an ethical commitment. In order to work for health, health workers ought to commit to a substantial theory of health. One such theory--the foundations theory of health--is briefly explained and illustrated. The foundations theory can form a shared ethical bond between health and social care professionals, since both professions regularly strive to achieve foundational health for their patients and clients.     

Mexican Perspectives on Adverse Events in Healthcare and Pain Management

ABSTRACT

Adverse events due to medical staff errors are a leading cause of morbidity and mortality around the world. One important aspect of this serious public health issue is mismanagement of pain, particularly pain associated to acute coronary events or cancer. In recent years, there has been increased awareness among international heath care communities on the importance of recognizing and reducing the mistakes committed on a daily basis in practically all medical settings. Unfortunately, most investigation and prevention programs are not designed around any theoretical framework on human error. Mistakes are rarely seen as a symptom of a larger problem. Rather than seeking to correct the root cause, the majority of situations are resolved on a case-by-case basis making it difficult to establish a cohesive prevention system. We suggest that future efforts should place emphasis on developing a uniform method of error detection and prevention, as well as improving and maintaining the patient–physician relationship. Medical education should be valued over litigation.     

Conflict in fiduciary duty involving health care error reporting.

Fiduciary duty is the responsibility to act in the best interest of a person or organization. Health care professionals, as well as managers in other industries, struggle continuously with the dilemma of whether or not to admit potentially harmful mistakes to unsuspecting customers and patients. Limited public disclosure of medical errors will benefit health care staff, organizational executives, and patients if specific policies are enacted to improve error prevention.     

Ethics Committees in Home Health Agencies

Home health care providers are increasingly faced with ethical dilemmas. Advancing technology, fiscal allocation guidelines, and patients requiring more complex care influence the delivery of services. Nurses providing home health care frequently must practice independently, and the possibility that they may not be adequately prepared in ethical decision making compounds the problem. As was the case in hospitals a decade ago, it is time to develop ethics committees in home health care agencies.     

Health Policy Dilemmas Related to High Technology Infertility Services

As cost containment in health care becomes an important concern, the costs and benefits of specific health care services will be more closely examined. The costs and benefits of one type of health care, high technology infertility services, are explored in this paper. These services may be particularly susceptible to cost containment since they are costly, raise ethical issues, and because they currently are provided to healthy individuals not experiencing life-threatening illnesses who can afford them.     

Finding blunders in thyroid testing: experience in newborns

We evaluated thyroxin (T4) and thyroid‐stimulating hormone (TSH) data along with clinical information from 600,000 newborns. We looked for certain combinations of tests and clinical data that were questionable and possibly mistaken. Our approach suggests that certain combinations of test results, especially the presence of missing results deserved further evaluation for possible blunders. We found that missing tests were frequently the result of oversight. The laboratory used the well‐known standard blood‐spot‐on‐filter paper methods for TSH and T4. For quantitation of TSH and T4, we used the time‐resolved fluoroimmunoassay available from Perkin Elmer. We found 56 babies with confirmed primary congenital hypothyroidism (PCH) in a total of 600,000 patients. We also found 18 sets of results in the same 600,000 babies that gave inconsistent findings, had missing values, and (or) possible misinterpretations of the clinical and (or) laboratory data. What is an acceptable mistake rate? All mistakes are unacceptable, but there is likely some irreducible mistake rate, and efforts to reduce the mistake or blunder rate still further may not be cost‐effective. What can be done is to study the mistake rate per 600,000 babies from year to year; the mistake rate should be decreasing or not changing. This assumes a stable cohort of babies; an assumption that may be acceptable. We applied a form of pattern recognition to identify cases of possible blunders and missing values in either the laboratory or clinical data. What is clear is that we apparently identified some blunders. The 18 mistakes per 600,000 babies may be “very low” and acceptable. We recommend that seeking ever decreasing mistakes is the way to go, and the level of monitoring the data should be very intense given the serious consequences of mis‐diagnosed thyroid disorders. J. Clin. Lab. Anal. 22:254–256, 2008. © 2008 Wiley‐Liss, Inc.     

Home study program. Can we build a safer OR?

PEOPLE WHO WORK in health care are among the brightest and most dedicated workers in the United States, but they are human, and humans make mistakes. HEALTH CARE FACILITIES are moving away from a culture of perfection and exploring how human factors predispose people to make certain types of errors. THIS ARTICLE discusses the types of errors being made and the organizations that are working to redesign the health care system to make it easier to do the job more safely and more difficult to make a mistake.     

Winding roads and faded signs: ethical decision making in a postmodern world

We are living in an era, sometimes referred to as "postmodern," exemplified by complex change related to vast increases in information and technology and exposure to diverse people and ideas. Society as a whole is experiencing dissonance in solving ethical dilemmas, and nurses' ethical dilemmas are never far removed from the social context in which nurses practice. This article explores aspects of postmodernism that complicate ethical decision making. It is hoped that this discussion may aid nurses in understanding how world values, especially those of postmodernism, complicate ethical decision making in health care. Suggestions melding aspects of the postmodern with traditional approaches to ethical decision making are presented.     

Toward a Theory of Self-Reconciliation Following Mistakes in Nursing Practice

PURPOSE: To explore nurses' responses to making mistakes in hospital-based practice in the US. METHODS: A grounded theory approach was used to explore the process that occurs after nurses perceive that they have made mistakes in practice. Theoretical sampling was used and data were collected until saturation occurred. Ten participants, who were registered nurses, described 17 personal mistakes. The mistakes they described occurred in hospitals. All participants were practicing nursing either in hospitals or in other work settings. FINDINGS: A process of "Self-Reconciliation After Making Mistakes in Hospital Practice" was identified, with four distinct categories: reality hitting, weighing in, acting, and reconciling. The core category was reconciliation of the self, personally and professionally. CONCLUSIONS: This research was a first step toward the development of a theory of mistake making in nursing practice. This response to making mistakes is consistent with previous research and is related to cognitive dissonance theory. The responses to mistakes varied from less healthy responses of blaming and silence to healthier responses that included disclosure, apologizing, and making amends. Further research to develop the theory and to determine helpful interventions is suggested.     

When patients and families disagree

Advance care planning is meant to safeguard the patient's autonomy when that individual is unable to make his or her own healthcare decisions. Yet, families do not always agree with the specific wishes of their family member when there is a need to make critical decisions, such as continuing treatment because of some new research protocol or providing comfort through palliative care. When there are patient-family disagreements, the decision-making process is even more complicated if the patient is fully able to participate because competent patients have the right to make their own healthcare decisions. In addition, family members may not agree with each other. Thus, even though healthcare providers want to respect their patients' wishes, they are uncertain about the most appropriate course of action. This article discusses why families and patients may disagree, describes relevant ethical perspectives for understanding the issues, and identifies possible strategies to help nurses address these ethical dilemmas. Valuing the patient as a person, the vulnerability of the patient, whose interests should prevail, and quality of life are pertinent and overlapping ethical issues in this case. Possible strategies that nurses can implement to address the "thorny" issues raised by patient-family disagreements include helping the patient to remain in control, facilitating responsible decision making, requesting an ethics consultation, and requesting a palliative care consultation.     

Should a ventilator be removed at a patient's request? An ethical analysis

The request of a ventilator-dependent quadriplegic person to be removed from the ventilator presents the health care team with an ethical dilemma. Application of ethical principles to case facts guides the decision maker. The ethical principle of autonomy requires that persons be respected and free to determine their course in life. The ethical principle of beneficence requires the health care team to actively benefit or do good for the patient. The ethical principle of nonmaleficence requires the health care team to refrain from harming a patient. The ethical duty of fidelity requires the nurse to be faithful to commitments made to patients. Ethical principles and duties are clear and straightforward. The decision of how they apply to a given case is not. However, applying them to a case, while not providing definitive answers, will provide the certainty that the decision was the best possible in a particular set of circumstances. An increasing number of cases similar to Joe's is being resolved in favor of discontinuing the ventilator. Emotional havoc could be the result to nurses who care for these patients. Individuals and institutions must begin planning strategies to deal with these and similar ethical dilemmas. Strategies might include anticipatory counseling, ethical decision making education programs and utilization of a nurse trained in ethics as a staff resource person. Nurses should attend and be involved in discussions of institutional ethics committees.(ABSTRACT TRUNCATED AT 250 WORDS)     

Pelvic inflammatory disease and sepsis

Pelvic inflammatory disease affects approximately 1 million women per year in the United States alone and has a variety of causative organisms. Because the diagnosis of PID is based on clinical judgment, health care providers need to be guided by the CDC recommendations for diagnosing and treating PID. Because presenting symptoms are often vague, the health care provider should assess female patients for risky behaviors that may lead to PID and should use screening data when making clinical judgments and differential diagnoses. Whenever possible, female patients with PID should be treated as outpatients. If diagnosis and treatment are not performed in a timely manner, PID may cause sepsis, septic shock, and even death. Even if they survive, as many as 15% to 20% of these women experience long-term sequelae of PID, such as ectopic pregnancy, tubo-ovarian abscess, infertility, dyspareunia, and chronic pelvic pain. The best treatments for PID are interventions that lead to prevention and early detection. The critical care nurse has an important role in recognizing the variables that may lead to PID-related sepsis and in encouraging health-seeking and health-maintenance behaviors among women with these diagnoses.     

Abandonment of patients by home health nursing agencies: an ethical analysis of the dilemma

Home health care nurses are facing the ethical dilemma of discontinuing care to nonpaying needy patients or facing agency economic demise. Nurses perceive discontinuing care under such circumstances as patient abandonment. Ethical analysis of the dilemma yields two conclusions: (1) discontinuing care under non-life-threatening circumstances is not abandonment and does not violate the duty of beneficence, and (2) nurses do have an obligation to inform society of such instances so that public policy decision makers can be armed with that information when making allocation decisions.     

Research Article: Perceptions of Japanese patients and their family about medical treatment decisions

Internationally, nurses and physicians are increasingly expected to undertake roles in communication and patient advocacy, including in Japan, where the reigning principle underlying medical ethics is in transition from paternalism to respect for patient autonomy. The study reports the results of a survey in two Japanese teaching hospitals that clarified the perspectives of 128 patients and 41 family members regarding their current and desired involvement in health decision‐making. The commonest process that was desired by patients and their family was for patients to make decisions after consultation with both the physician and their family. The decision‐making preferences for competent patients varied among the participants, who believed that families have a crucial role to play in health‐care decision‐making, even when patients are competent to make their own decisions. The findings will inform health professionals about contemporary Japanese health‐care decision‐making and the ethical issues involved in this process, as well as assist the future development of a culturally relevant model to support patients' preferences for ethical decision‐making.     

Ethical issues in nursing leadership

Social transition causes shifts and changes in the relationship between health professionals and their patients. In their professional capacity, it is important today for nurses to handle ethical dilemmas properly, in a manner that fosters an ethical environment. This article investigates the ethical concerns and decision processes of nurses from a knowledge construction perspective, and examines such issues as patient needs, staff perceptions, organizational benefits, and professional image. The decision making methods commonly used when facing ethical dilemma explored in this study include the traditional problem solving, nursing process, MORAL model, and Murphy's methods. Although decision making for ethical dilemmas is governed by no universal rule, nurses are responsible to try to foster a trusting relationship between employee and employer, health care providers and patients, and the organization and colleagues. When decision making on ethical dilemmas is properly executed quality care will be delivered and malpractice can be reduced.     

Doctors' and nurses' perceptions of ethical problems in end-of-life decisions

AIMS: To identify and compare doctors' and nurses' perceptions of ethical problems. Rationale. Ethical problems are a source of tension for health professionals. Misunderstandings or conflicts may result from differing perceptions of ethical problems. If true collaboration is to be achieved, it is important to understand the perspectives of others, particularly when difficult end-of-life decisions must be made. METHODS: In this qualitative study a total of seven doctors and 14 nurses working in acute care adult medical-surgical areas, including intensive care, were asked to describe ethical problems that they frequently encounter in practice. Interviews were taped and transcribed. Thematic analysis followed. RESULTS: All participants experienced ethical problems around decision making at the end of life. The core problem for both doctors and nurses was witnessing suffering, which engendered a moral obligation to reduce that suffering. Uncertainty about the best course of action for the patient and family was a source of moral distress. Competing values, hierarchical processes, scarce resources, and communication emerged as common themes. The key difference between the groups was that doctors are responsible for making decisions and nurses must live with these decisions. Each group, therefore, asked different questions when encountering and interpreting sources of moral distress. CONCLUSIONS: It was concluded that observed differences between doctors and nurses were a function of the professional role played by each rather than differences in ethical reasoning or moral motivation. Although this was a small qualitative study on one institution, and may not be generalizable, results suggest that doctors and nurses need to engage in moral discourse to understand and support the ethical burden carried by the other. Administrators should provide opportunities for discourse to help staff reduce moral distress and generate creative strategies for dealing with this.