Case scenario

Assignment week 8
Read this case scenario and write your analysis using material from “Resources week 8”

Case scenario

On the other end of the phone was Jane a long time practice manager for a local family practice office. There was concern and sadness in her voice today. She explained that they had had a medication error event recently and the way it was handled has bothered her for the past week. She did not want this to happen again, the error for sure, but the way the practice approached the employee involved even more. The physician had written an order for a medication injection. The physician’s handwriting was difficult to read but after many years working together the medical assistants and nurses were used to deciphering what was written and often asked each other for confirmation. The medical assistant believed she had correctly read the order and drew up the medication dose and administered it to the patient. Unfortunately, the dose as she read it was incorrect and resulted in a medication over dose for the patient. The physician-owner and boss were furious and demanded that Jane fire the MA immediately. The physician stated that it was necessary to appease the patient and assure the patient that this error would not happen again. Jane added that she felt the physician was avoiding personal accountability for the years of poor hand writing practices and the impact that had on this error. This MA had had two previous medication related errors that had resulted in a warning and then a disciplinary write up. There had never been an investigation into the cause of the previous errors only admonishment that she must pay closer attention to detail. Jane did as instructed by her boss and fired the MA.


Margaret A. Curtin, “Quality Improvement, Patient Safety & Efficiency in Outpatient Practice” p. 46. Retrieved from:

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