Week 4: Discussion
In September 2023, two Southern California hospitals received attention for medication errors.
An 81-year-old patient at Adventist Health Simi Valley died from a brain bleed after getting two
doses of the blood thinner Lovenox in a short period. Studies have found that administering an
overdose of blood thinners can lead to exacerbation of bleeding and ultimately result in
fatalities (Santos et al., 2020). Similar to this, at Northridge Hospital Medical Centre, a patient in
recovery from anesthesia following surgery needed resuscitation due to being given a blood
pressure medication instead of Naloxone, which is used to reverse opioid effects.
Aside from the adverse effects resulting in physical hurt and deterioration of health for the
patients, and presumably severe emotional distress for both the patients and their families,
there is currently no mention of the staff facing any repercussions.
State investigators discovered medicine administration errors at both hospitals due to physician
orders not being followed. It was also clear that there was a lack of communication among
healthcare professionals, especially regarding medication administration. Both hospitals failed
to modify medication dosages based on specific patient factors, and the Adventist Health Simi
Valley nurses were unaware of a previous Lovenox dose, which could have prevented
subsequent dosing errors. These errors might also be attributed, in part, to underutilizing
individualized drug dosing because modern medicine usually adheres to standard dosing
established by randomized controlled trials (Tyson et al., 2020). Finally, it is important to
enhance communication channels among healthcare providers to stop similar mistakes from
happening again. Establishing standards for adjusting drug dosages according to patient
characteristics is also essential. Maintaining compliance with hospital standards and staff
education is still crucial, as providers are dealing with human lives and should handle them with
the utmost care. Hospitals can protect patient welfare and maintain their dedication to high-
quality care by tackling these problems.
References
Santos, J., António, N., Rocha, M., & Fortuna, A. (2020). Impact of direct oral anticoagulant
off label doses on clinical outcomes of atrial fibrillation patients: A systematic review. British ‐
Journal of Clinical Pharmacology, 86(3), 533–547. https://doi.org/10.1111/bcp.14127
Tyson, R. J., Park, C. C., Powell, J. R., Patterson, J. H., Weiner, D., Watkins, P. B., & Gonzalez, D.
(2020). Precision dosing priority criteria: Drug, disease, and patient population variables.
Frontiers in Pharmacology, 11. https://doi.org/10.3389/fphar.2020.00420
Reyes, E. A. (2023, September 25). Hospital medication errors left SoCal patients at risk. One
suffered a brain bleed. Los Angeles Times. https://www.latimes.com/california/story/2023-09-
25/hospital-medication-errors-jeopardized- socal-patients-brain-bleed
