A Case Study of Premature Delivery of the 23 Weeks Old Baby

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The case study regards a situation where alleged dispensing of the wrong drug resulted in the premature delivery of a fetus with brain damage of 23 weeks old. The plaintiff was a 23-year-old pregnant lady with slight vaginal bleeding due to inadequate cervix who was admitted to the inpatient obstetrical unit for bed rest and further observation. The physician ordered the patient to be put on progesterone suppository to control further bleeding.

The defendant pharmacist was feeling quite unwell and requested for leave and was granted the permission to do so. Basing in mind that it had been quite a busy day, she sought need to wait for the arrival of the relieving pharmacist to reduce the inconsistencies when no one was on duty. Since the relieving pharmacist took long to arrive, the order for the progesterone was received and handled by the defendant pharmacist before leaving who was quite unfamiliar with the progesterone. It was later on confirmed that the hospital had not handled this drug for several years. Even after computerizing the drug mnemonics that brought the drug Prostin on screen, she ended up dispensing Prostin suppositories believing it was collectively the same thing. However, Prostin is a cervical ripening agent used for abortion procedures and providing opposite clinical effects as Progesterone. As such, it led the patient into labor leading to premature delivery of the 23weeks baby. It caused severe impairment of the baby that necessitated ventilator support and intubation that forced transfer to a specialized hospital for adequate and total care. However, the incident included multiple co-defendants who are not mentioned. The monetary value represents the amount of cash paid on the defendant’s behalf. Despite there being other errors committed by the rest of defendants, the entire recommendations will be generated basing on the actions of the pharmacist, the defendant. 

The Ethical Principles Involved from the Perspective of the Patient, Pharmacist, and the Organization

From the pharmacist’s perspective, she should have made further investigations on the ordered drug because she was unfamiliar with it. Upon keying in the drug descriptions into the machine, she should have questioned further about the differences in the naming of drugs, made further researches or consulted the physicians for further clarifications on order made (Abdulhamid, 2018). The subsequent litigation, therefore, involves both the nurse and the hospital at large due to the evident organizational disparities. The nurse had failed to adhere to the hospital and pharmacy safety policies due to her negligence (Alsaeed, 2015). Therefore, it led to tendering her full policy limits following the infant’s need for a lifelong and full-time quality care.

The Legal Implications and the Laws Involved

The legal implications here were the resultant medical malpractices that led to the assertion of medical pharmacists. This malpractice resulted in an intentional act of negligence that led to the premature delivery of the 23 weeks fetus and development of subsequent brain damage. The law involved in this case if the Law of Practicing Healthcare Professionals (LDHP) that sets forth specific standards for all licensed healthcare professionals (Chen & Yang, 2014). They pertain to liability for medical errors as well as licensing requirements. The LPHP, therefore, necessitates all dentists and physicians on duty to facilitate maintenance of malpractice insurance regardless of whether it is a public or private healthcare institution (Alsaeed, 2015). Clearly, in the event of the defendant pharmacist trying to maintain on duty to avoid errors before the arrival of her replacement, her health condition and the quick deliver of order by the pharmacy are the main factors in her lack of judgement towards the resultant medical dispensing error (Cheng & Yang, 2014). However, the defendant pharmacist equally did not use the appropriate pharmacy safeguards and procedures in preventing the inadvertent errors.

Recommendations for Managing this Case from the Perspective of the Healthcare Organization

There is a lot that could have been done to avoid the resultant situation. The nurse would not have dispensed a drug that she was not sure of or unfamiliar with before performing appropriate research. Ensuring that the current drug under research is provided within the programming of each pharmacy computer to ensure it was automatically updated (Abdulhamid, 2018). The nurse could also have adhered to the pharmacy protocols upon entering the drug’s name into the computer and only give it to the patient if the sig codes or mnemonics were approved. In this case, she failed to consider the resultant override of the computerized warning as a crucial incident that calls for regular problem review to ensure all system errors were identified, any improper or inadequate codes noted, recognition of incomplete formulary or resultant issues from the practitioner orders to avoid technician competency issues and resultant errors (Cheng & Yang, 2014). She assumed the similarity in the sounding of names (Prostin and Pregesterone) as being equivalent that resulted in sound-alike errors that necessitated separate identification using the visible warning labels. If the prescribing practitioner for any potential interactions and contradictions or would have been contacted or supervising director consulted, then the rectifications would have been made (Alsaeed, 2015). Finally, there was a need for checking the prescriptions prior to dispensing. Hence, it is better done by a second pharmacist for purposes of additional safety. The prescriptions should have been checked against the original order for verification reasons to ensure it was the right drug destined for the appropriate patients.

Implementation Procedures for Preventing Future Occurrences

Risk management comprises an integral part of the standard business practices for any healthcare organization. It entails risk identification and recommendation or implementation of most potential control procedures. The following are a distinct recommendation that can be put in place to reduce the probability of future occurrences.

There is a need to establish effective communication strategies between patients and the medical staff. Clear and concise interaction with colleagues, staff, and patients ensured avoidance of inconsistent errors and related misunderstandings (Abdulhamid, 2018). Patients are notably reluctant to press charges against a physician that took time to explain all medical procedures and answers to their pressing questions. Moreover, seeking a second opinion is equally crucial. According to risk management specialists, the major cause of malpractice litigation is the concept of misdiagnosis. Seeking second opinions should be done by a colleague with wider medical experience by the case under evaluation (Alsaeed, 2015). Hence, it will restrict direct withholding of the management team regardless of whether it is an administrative, financial or social issue mostly for the case of private sector facilities. It is equally important to obtain a detailed and a thoroughly informed patient consent with definite diagnosis made, the management plan as well as the expected complications likely to be encountered (Chen & Yang, 2014). Finally, there is a need to document any medical decisions made, communications and recommendations established with regard to any patient case and in a timely detailed manner.


Abdulhamid Hassan Alsaeed; Department of Anaesthesia and Critical Care Medicine, College of Medicine, King Saud University, Riyadh 11472, Saudi Arabia. “The scope of medical litigations in Saudi Arabia – Analysis of closed claims over 15 years”. Retrieved on 10th April 2018.

Alsaeed, A. H. (2015). Revisited: The scope of medical litigations in Saudi Arabia ­ Analysis of closed claims over 15 years (http://www.thejhs.org/article.asp?issn=2468­

6360;year=2015;volume=3;issue=3;spage=162;epage=165;aulast=Alsaeed;type=0 ). Journal of Health Specialties, 3(3), 162-165.

Chen, B. K., & Yang, C. (2014). Increased perception of malpractice liability and the practice of defensive medicine (http://onlinelibrary.wiley.com.sdl.idm.oclc.org/doi/10.1111/jels.12046/full). Journal of Empirical Legal Studies, 11(3), 446–476.

Renkema, E., Broekhuis, M., & Ahaus, K. (2014). Conditions that influence the impact of malpractice litigation risk on physicians' behavior regarding patient safety (https://searchproquest­com.sdl.idm.oclc.org/docview/1492793011? Accountid=142908). BMC Health Services Research, 14, 1-6.

January 19, 2024

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