Sample Case Study Paper on Medication Safety Analysis

Although not entirely commonplace, medical errors are among the incidences medical practitioners and organizations have to deal with occasionally. The occurrence of such incidences can have debilitating effects on individual practitioners including jail terms, fines and stripping off practice license. Medical facilities on the other hand, may be open to litigation in lawsuits, tainted reputation and image, and the loss of public confidence in the facility or region in cases where the incidence involves a health region, as was the case of Calgary Health Region (Johnston et al., 2004). It is for this reason that hospitals monitor these errors as part of their quality-of-care programs (Marshman et al., 2006). In looking at medical error, their consequences, the contribution of the errors, the discovery and handling of the errors and strategies recommended in prevention of the errors, this analysis will delve into the Foothills and Eric Cropp incidences of medical error and their consequences.

The controversy at Calgary Health Region did not end with the death of the patient who walked from two of the Region’s two busy emergency departments before receiving treatment (Johnston et al., 2004). While this medical negligence on the part of the Region’s medical practitioners was only a subject of internal investigation, the medical error at Foothills Medical Center found its way into the public domain, especially after the Center reported the issue to the media (Johnston et al., 2004). In the mishap, the Regional Pharmacy Services, a centrally place large pharmacy that served Calgary Region had made a mistake in preparing dialysis bags (Johnston et al., 2004).

Due to the similarities in the bottling and labeling of potassium chloride and sodium chloride, save for the capping, the pharmacy staff had used potassium chloride rather than sodium chloride in the preparation of the dialysis bags (Johnston et al., 2004). The error had gone undetected through all the four check processes and found the bags found their way to Foothills Medical Center, where they were used on patients. The result of this error was the death, through hyperkalemia, of a patient undergoing renal replacement at the hospital’s ICU (Johnston et al., 2004). Another patient undergoing renal replacement and having developed hyperkalemia drew the attention of the medical staff at the hospital to the dialysate solution, where there was a discovery that it contained 53.6 mmmol/L potassium, while it should not have had any (Johnston et al., 2004).

While Foothills Medical Center’s admission of the incident had caused a media frenzy into the circumstances surrounding the occurrence of the error, no one received a jail term. This contrasts Eric Cropp’s case, a pharmacist whose medical error landed him a six-month sentence; an additional six months in home confinement, $5,000 in fine and payment of court costs (Cohen, 2009). Additionally, Cropp has to serve 3 years in probation, as well as 400 hours of community service. Cropp had made a human error, wherein he failed to recognize the high concentration of sodium chloride in the making of the chemotherapy solution by a pharmacy technician under his supervision (Cohen, 2009). The final solution had 20% sodium chloride concentration, while it should have been 0.9% sodium chloride concentration. The result was the death of the young child who was undergoing chemotherapy treatment due to the high sodium chloride concentration in the solution.

In looking at Cropp’s incident, one cannot fail to wonder what circumstances had caused the human error. While similarity in bottling and labeling had been the cause of error in the Foothills Medical Center, a number of factors were at play for Cropp’s human error. According to Cohen (2009), the pharmacy computer system had broken down on the day of the incident.  Moreover, the pharmacy technician preparing the intravenous solutions was planning her wedding, and was therefore, naturally distracted. Even more was that with the breaking down of the computer system, there was a backlog of physician’s orders, adding more time pressure on Cropp. An immediate request by a nurse for the chemotherapy solution escalated Cropp’s time pressure, and ultimately contributed to his missing of the error made by the pharmacy technician, eventually causing the death of Emily (Cohen, 2009).

In the discovery of the medical error incident at Foothills Medical Center, the development of hyperkalemia in the patient undergoing continuous renal replacement drew the attention of the medical personnel at the hospital to the dialysate solution (Johnston et al., 2004). The analysis of the solution led to the discovery that the solution had 53.6 mmmol/L potassium, while it should not have had any. On this discovery, the medical personnel took to action, removing all the bags of the dialysate from ICUs in the region. Following this discovery, the hospital instituted a review into previous incidences and discovered a patient undergoing a similar procedure had died, with his hyperkalemia attributed to extreme acidosis and tissue necrosis (Johnston et al., 2004).

Following the incident, the region instituted a Regional Critical Incident Review process, which discovered that the error emanated from the Central Production Pharmacy. The pharmacy supported the four acute care hospitals in the Calgary Health Region, and although separate from the site hospitals, it operates under the Regional Pharmacy Services (Johnston et al., 2004). The immediate response to the incident was the recalling of the batches with the error and putting warning labels on all the potassium chloride bottles. The next action involved the changing of the sodium chloride supplier to alleviate any chances of a repeat bottle similarity incidence (Johnston et al., 2004).

The above response was largely internal within the Region’s supply and labeling processes. Handing the matter in reference to communication was the greatest challenge. As a way of making up for past controversy and instilling the virtue of full disclosure of medical errors among the staff, the Region’s executive committee voted to make a public disclosure (Johnston et al., 2004). Apart from instilling honesty as a virtue and taking of responsibility, the Region’s intention in the disclosure was to challenge other health care providers to make public disclosures of errors as a way of supporting system change and reduce future occurrence of similar incidences (Johnston et al., 2004).

On the other hand, Cropp’s human error came to light after Emily suffered a terrible headache and thirst, quickly relapsing into a coma and eventually dying (Cohen, 2009). At the discovery of the incident, investigations into the events prior to Emily’s death unearthed the technician’s error at having used three vials of 23.4% sodium chloride instead of one; an error that Cropp did not notice on checking the solution (ISMP, 2009). The Ohio Board of Pharmacy became involved in the hearing after the incident, which led to the revocation of Cropp’s license with no possibility of appeal against the board’s decision. The aftermath of the Board’s decision led to the criminal prosecution of Cropp’s, the Cuyahoga County district attorney charging Cropp with reckless homicide and manslaughter (ISMP, 2009). Cropp later received his sentence after pleading guilty to an involuntary manslaughter charge, receiving the 6-month sentence, fine, community service 3-year probation.

Given the presence of humans in the medical field, errors are bound to happen. However, this does not mean that these errors cannot be prevented. One of the strategies for the prevention of medical errors involves recording and reporting the errors. According to Marshman et al. (2006), systematic compilation of medication errors facilitates the analysis of the errors, and eventual learning from these errors to avoid future pitfalls. The policy on reporting and documenting errors should work in such a way that the individual who has committed the error is not criminalized, as has been the case in numerous occasions. Error recording and reporting should not only be the base for learning, but also making practice improvements.

The National Association of Pharmacy Regulatory Authorities (NAPRA) has standards of practice aimed at preventing the errors. One of the strategies is in human resources, where they suggest that technical work in drug mixing and dispensation should be the work of technicians. The technicians in this case should have certification or technical training in handling the drugs. Further, it is also advisable that pharmacist should have two technicians as a way of ensuring double-checks in prescriptions and mixing procedures. Clutter and interruptions within the pharmacy may also be a cause of the errors; therefore, it is important to minimize interruptions in the pharmacy, while at the same time ensuring that traffic in the dispensary is at a minimum.




Cohen, M., R. (2009). An injustice has been done: Jail time given to pharmacist who made an error. ISMP.

ISMP (2009). Eric Cropp weighs in on the error that sent him to prison. ISMP.

Johnston, R., V. et al. (2004). Responding to tragic error: lessons from FoothillsMedical Centre.CMAJ, 170(11), 1659-1160

Marshman, J., A. et al. (2006). Medication Error Events in Ontario Acute Care Hospitals. CJHP, 59(5), 243-250