This case study describes a medical error that occurred in the intensive care unit. Two patients, Mr. Lucas and Mr. London, were admitted emergently and in critical condition. In the rush to fill orders, the pharmacy incorrectly labeled the IV bags, resulting in Mr. London receiving heparin instead of octreotide. As a result, the wrong drugs were administered to each patient. The pharmacy supervisor discovered the error after one patient had died. The case raises issues around patient safety, ensuring the right medications are given to the right patients, and preventing medical errors during busy times.

1. The professional decision-making
process
Case Study
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2. CASE STUDY
 Two pharmacists were reprimanded (rebuked ) by the
Statutory Committee in 1991 following convictions for
the supply to a 17-year-old youth of sodium cyanide in
one case and strychnine hydrochloride, potassium
permanganate (a strong oxidizing agent) and glycerol
(Sugar alcohols) in another.
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4. CASE STUDY, CONT…
 Why were such supplies considered wrong?
 What thought processes should have been gone
through in reaching a decision as to whether to supply?
 Pharmacists are permitted to supply all these
substances from a pharmacy, so why were convictions
as well as a reprimand given?
 Would it have been right to supply in other
circumstances?
 If so, on what knowledge would you have based your
decision?
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5. STAGE 1: GATHER RELEVANT FACTS
What is needed before any decision can be taken is
collect as many facts as possible. We shall call
this:
Gather relevant facts
1- What criminal law applies here?
 First, you want to know what the criminal law
says. Ask yourself, ‘will I be breaking the law if I
supply?’
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6. STAGE 1: GATHER RELEVANT FACTS CONT
 In the case of potassium permanganate, you may
supply, but there are packaging and labelling regulations
to consider. You may supply glycerol; indeed, you can
buy glycerol (or glycerine) from the food shelves of a
supermarket.
 Neither of these substances is controlled as a medicine
or a poison. Sodium cyanide and strychnine are both
Part I, Schedule 1 poisons with special conditions
attaching to their supply.
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7. GATHER RELEVANT FACTS CONT
 Most of the criminal law that applies to pharmacy
practice will be in the Medicines Act, the Misuse of
Drugs Act or the Poisons Act, although there is a whole
range of other criminal legislation that may apply, e.g.
the Environmental Protection Act, the Health and Safety
at Work, etc. Act, the Customs and Excise (taxation)
Management Act.
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8. GATHER RELEVANT FACTS , CONT
What NHS law applies here?
In this example, you do not have to consider national
health service (NHS) law because the supply is a
‘private’ one and not within the terms of the NHS
contract.
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9. GATHER RELEVANT FACTS , CONT
What civil law applies here?
 In this example, the young man managed to cause an
explosion by using glycerol and potassium permanganate
together. Would the supplying pharmacist have been partly to
blame for any damage that may have resulted? To some
extent, yes, because pharmacists are expected, by virtue of
their expertise and training, to exercise a greater duty of care
than other retailers over the supplies they make.
 In the case of strychnine and cyanide, sales are restricted to
pharmacies precisely because pharmacists are expected to
know the dangers inherent in their use and only to supply
responsibly after due enquiries have been made.
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10. GATHER RELEVANT FACTS , CONT
What guidance does the Code of Ethics give here?
As a pharmacist, you have to meet standards that are in
excess of the minimum that the law requires. At the
time of this case, the Code of Ethics said ‘A pharmacist
must take steps to ensure that all chemicals supplied
will be used for a proper purpose and in appropriate
circumstances’.
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11. GATHER RELEVANT FACTS , CONT
 The Code went on to give guidance that all oxidising
agents, such as potassium permanganate, may be used
for the preparation of explosives. (Such requirements
are now implicit in the legal requirement to exercise
‘due diligence (careful and persistent work or effort)’
when supplying any chemicals.) . What enquiries should
you make? What facts will you need to show that you
made reasonable enquiries to satisfy these
requirements?
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12. GATHER RELEVANT FACTS , CONT
5- What professional knowledge do I have that applies
here?
 In spite of all the legal and ethical constraints or
guidance that you are aware of, you will also be applying
your technical and clinical knowledge to the situation.
 You probably learned in chemistry classes that certain
chemicals make explosive combinations.
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13.  You would know that cyanide and strychnine are very
potent poisons.
 Many of the problems you encounter in pharmacy
practice will require the use of your knowledge of
therapeutics, pharmaceutics, good pharmacy practice,
etc., as well as knowledge of law and ethics.
GATHER RELEVANT FACTS , CONT
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14. Where can I look or whom can I ask for help?
Finally, but just as important as any of the above, is
whether there is any precedent you can follow, any
policy that covers this situation, any other ‘rule book’ or
senior pharmacist that perhaps you should consult.
 Many pharmacists are employees who will have
corporate protocols and procedures to follow and, most
valuable at the start of a career, a range of experienced
pharmacists who can be asked for advice.
GATHER RELEVANT FACTS , CONT
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15. STAGE 2: PRIORITISE AND ASCRIBE VALUES
 In this example, the fact that the purchaser in the above
example is male is interesting but not important; his
age, however, may influence your eventual decision.
 Even if the purchaser were a middle-aged respectable-
looking individual, you might still consider the nature of
the substances or combination of substances to be of
overriding importance. You are prioritizing the facts.
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16. STAGE 2: PRIORITISE AND ASCRIBE VALUES ,CONT
 Moreover, you want to weigh up the consequences for
yourself, perhaps for your employer, for the young man,
for his parents and neighbors and for the reputation of
pharmacy of making these supplies or not.
 The relative importance you attach to these issues will
also depend on your own personal opinions and
attitudes. In other words, you are ascribing values to the
facts you have assembled.
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17. STAGE 3 GENERATE OPTIONS
 In other words, ask yourself: ‘What could I do in this
situation?’
 In this example there will be at least four options:
1. Supply none of the items
2. Supply all of the items
3. Supply some of the items
4. Delay to seek advice.
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18. STAGE 3 GENERATE OPTIONS ,CONT
 You might suggest other variations such as selling
some or all of the items, subject to certain
conditions, such as a written request specifying
reason for purchase or giving the authority of
someone you know to be responsible.
 By careful analysis, you will be able to establish the
likely consequences of each course of action and
then choose which will have the best chance of a
good outcome or, in some cases, the least likelihood
of causing harm.
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19. STAGE 4 CHOOSE AN OPTION
 Stage 4 Choose an option
 In other words ask yourself: ‘What should I do in this
situation?’ Remember that, when making your choice,
you may have to be able to justify why you made that
one.
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20. SUMMARY OF THE FOUR-STAGE DECISION-MAKING
PROCESS.
Stage Components
1. Gather relevant facts: what applies
here?
Criminal, NHS and civil law
The Code of Ethics
Council statements
Professional and other knowledge
2. Prioritise and ascribe values: what
are the interests of various parties ?
The patient
The Public
Carers
Relatives and neighbours
Other healthcare professionals
The pharmacy profession
Your employer
Yourself
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21. SUMMARY OF THE FOUR-STAGE DECISION-
MAKING PROCESS ,CONT
Stage Components
3. Generate options What could you do?
What are the possible consequences
of each option?
How likely are the consequences?
4. Choose an option What should you do?
Can you justify the chosen option?
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22. THE FIVE-STEP MODEL
There is another model for ethical problem Solving
1. Respond to the “sense” or feeling that something
is wrong.
2. Gather information/make an assessment.
3. Identify the ethical problem/consider a moral
diagnosis.
4. Seek a resolution.
5. Work with others to determine a course of action.
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23. The End

24. CASE STUDY “AN ASSIGNEMNT”
 Roger Lucas, 70 years old, was admitted to the medical intensive care
unit from the surgical floor of the hospital with what appeared to be
a pulmonary embolism. Mr. Lucas had fractured his femur in a fall at
the nursing home where he is a patient and was awaiting surgery the
next morning when he developed dyspnea, tachypnea, and
tachycardia. At almost the same moment that Mr. Lucas arrived in the
ICU, another patient, Ronald London, was admitted in the next room
under equally emergent conditions. Mr. London was 60 years old and
had a history of liver cirrhosis from alcohol abuse. Mr. London had
ruptured esophageal varices. Helen Fowler, Pharm.D., was the
pharmacy supervisor for the evening shift for the six intensive care
units in the hospital. She and two other pharmacists worked
frantically to fi ll all the orders for intravenous drugs and parenteral
solutions that came from the intensive care units.
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25. CASE STUDY ,CONT
 Later, after the rush had subsided, Dr. Fowler decided to
conduct rounds and learned that Mr. London had died.
The code team was still picking up their equipment when
Dr. Fowler got to the unit. “That’s a shame,” Dr. Fowler
said to the nurse who was straightening up the room and
conducting postmortem care so that Mr. London’s family
could spend some time with him before his body was sent
to the morgue. Then Dr. Fowler noticed the label on the IV
bag in the trash, the one that had held the IV the nurse
had just removed from Mr. London’s arm. Dr. Fowler was
shocked to see that the empty IV bag included heparin,
not the octreotide he should have received. A
hemorrhaging patient should never receive heparin.
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26. CASE STUDY ,CONT
 Without saying anything to the nurse, Dr. Fowler
stepped next door to see what solution was hanging in
Mr. Lucas’s room. Much to her dismay, Mr. Lucas was
receiving octreotide when he should have been
receiving heparin. And, the two names had been
switched on the labels. In the rush and confusion
surrounding the admissions and the critical nature of
both patients, the IVs were inappropriately labeled.
Apparently no one checked the bags for the name of the
drug before hanging them since in each case the
patient’s name and room number were correct.
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27. COMMENTARY
 This case is complex but reveals potential ethical
concerns. As the pharmacist involved in the case, Dr.
Fowler will need to decide what she needs to do and
why. The five-step model can help Dr. Fowler work
toward a justifiable resolution.
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28. 1. Respond to the Sense That Something Is
Wrong
2. Gather Information
3. Seek Resolutions
4. Work with Others to Choose a Course of
Action
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Follow the following hints to make a good decision?