The Example of an Adverse Event

This paper is aimed at discussing the medication error that resulted in the death of a teenage girl named Vanessa Anderson. This case was one of the events that led to the investigation of the patient care practices adopted by medical workers, especially who are working in intensive care units (Golfball girl’s family hails health inquiry, 2008; Skinner, 2008). It should be noted that the patient was admitted to Hornsby Hospital with a skull fracture.

Later she was transferred to the Royal North Shore Hospital. Her injury was classified as a mild one on the basis of the Glasgow Come Score. At the beginning, Vanessa was supposed to take the drug named Dilantin; however, it became known that the patient’s brother had an allergic reaction to this drug (Inquest into the death of Vanessa Anderson, 2007). The physician, Dr. Williams, learned about this issue; but she did not discuss the origins of this allergic response. Apart from that, the professional did not consider various alternatives to Dilantin. For instance, one can speak about Epilum which is widely used in such cases (Inquest into the death of Vanessa Anderson, 2007).

In turn, Dr. Williams chose a more potent drug, namely Panadeine Forte, but she did not discuss this decision with her colleagues. In turn, the anesthesiologists, Dr. Ismail, pre-scribed the increased dosage of Endone in response to the severe pain experienced by Vanessa (Inquest into the death of Vanessa Anderson, 2007). Apparently, this physician disregarded the fact that the patient had already been given a very strong analgesic. Later, Vanessa called for assistance. The nurse, who responded to her call, did not believe that Vanessa had been in immediate danger. In her opinion, the patient’s distress could be caused by a mere nightmare.

Furthermore, this medical worker noticed that the patient had been administered a rather unusual combination of Panadeine Forte and Endone. Nevertheless, she did not discuss this issue with other physicians. She took the decision of physicians for granted. This is one of the details that can be distinguished. Admittedly, she reported Vanessa’s distress call to the physicians, but they also believed the life of a patient had not been endangered (Inquest into the death of Vanessa Anderson, 2007). Later, Vanessa fell unconscious, and CPP had to be administered immediately. However, the efforts to revive the patient were unsuccessful, and she died of the cardiac arrest which was caused by opiate medication.

It is important to mention that the medication errors were identified only after the death of the patient. In particular, one should speak about the examination of the coroner who had to identify the causes that contributed to this tragedy. In particular, it was necessary to carry out the post-mortem investigation. Additionally, it was necessary to interview the physicians and nurses who treated Vanessa. These interviews enabled the coroner to identify the factors that led to this tragedy.

In this way, one could better understand the decisions of healthcare professionals whose work was poorly coordinated. Overall, this case exemplifies an adverse event that could be avoided provided that healthcare professionals communicated with one another at the time when they took medication decisions (Attarian, 2008). These are the main details that can be singled out. To a great extent, they are important for understanding the way in which such errors can be averted.

Reference List

Attarian, D. (2008). What is a preventable adverse event? Web.

Golfball girl’s family hails health inquiry. (2008). Web.

Inquest into the death of Vanessa Anderson. (2007). Web.

Skinner, G. (2008). Pediatric Patient Oversight. Web.