CASE STUDY

WRONG MEDS AGAIN

TO

PROF AYMAN ABU SHARKH

 CASE STUDY-WRONG MEDS AGAIN

MAIN ISSUE
Giving wrong medicine to patient.

BASIC ISSUE
 The staffs asked the patient who is an old man about his medication and believed it .
 The medication list at the nursing home was ignored.
 It takes lot of time for the medication list to be updated online.
 Wrong medicine was given to the patient which is dangerous.

ASSUMPTIONS
 The hospital was not a big one but just nearby hospital he was taken to as it was an
emergency.
 The staffs do not look experienced as they blindly believe the man about what he
said about his medication.
 There is very less communication between the paramedics or emergency team and
hospital staff.
 Absence of leadership or guidance, there is nobody who can coordinate the process
like a supervisor.
 As the patient was brought in late at night, there may be very less staffs at night
which could’ve cause the delay in updating medical list .
 Patient was given medication based on a previous admission two years ago, we can
see that they treated the patient with enough and wrong information.

ANALYSIS
As we go through this case study, we can observe there are many discrepancies in the
process right from the part where the medication list is missing which could be the
carelessness of the emergency unit or could be negligence of the hospital staff. Then we can
see some lack of professionalism when the staffs ask the patient for medical information
and blindly believing it rather than verifying how genuine the patient’s statement were.
Then they asks the bystander for information and records what she says but they could not
update the database which results in recollection of the data from nursing home which is
faxed to the hospital but is of no use as it could not be read. This shows that hospital do not
conduct regular inspections on equipment .And then comes the major mistake of
administering medicine to the patient based on record from two years ago. This is lack of
experience, skilled staffs in the hospital. The hospital also needs to improve their technical
infrastructure to provide service.
RECOMMENDATIONS/SUGGESTION
 Standardising the procedure during an emergency. A well-structured procedure
should be created which has to followed while attending an emergency. This can
include gathering of the medical history of the patient and medications he takes.
 Interlinking of hospital database-Any data uploaded to the data must accessible to
every staff in the hospital.
 Collect information from nursing home when a patient is transferred to the hospital.
 Medicines should administered after thorough investigation.

PROCESS MAP-CURRENT PROCESS

EMERGENCY TEAM TAKES

THE PATIENT

INFORMATION COLLECTED
FROM PATIENT

COLLECTS WRONG DATA

DELAY TREATMENT

TAKE MEDICATION LIST

FROM RELATIVE

DOES NOT GET UPDATED

COLLECTS DATA AGAIN

MAKES MISTAKE IN
TREATMENT
PROCESS MAP-REVISED PROCESS

EMERGENCY TEAM TAKES

THE PATIENT

INFORMATION COLLECTED
FROM NURSING HOME

ALL THE INFORMATION IS

COLLECTS ALL MEDICAL
UPLOADED ON DATABASE
HISTORY

TREATMENT IS STARTED
BASED ON LATEST INFO
NURSING

TREATMENT IS DONE
BASED ON LATEST INFO