1. Trace the path of the medication list and denote possible failure points. Construct a process flowchart of the existing process and create a new chart of an improved process.
2. Was the medication error a failure of individuals or a failure of the process? Explain.
3. Think about the different settings, the ambulance, the emergency room, the hospital room, and the nurse’s station. How is data handled in each scenario? Can the process of recording information be changed so that every one is using the same data? How can the accuracy of the data be assured?
4. Given Melanie’s reaction, do you think this error will happen again? Why or why not?

“It was horrible,” said the distraught client. “No matter how many times I provided the information, no one listened to me. And they obviously didn’t listen to each other either, because they used the wrong meds . . . again.” “Okay, calm down. Now tell me what happened from the beginning,” urged Melanie Torrent, the Quality Assurance Manager for Hope Memorial Hospital. “I got a call at work saying my father was being taken to the hospital from the nursing home. The nursing home always sends a list of medications with the ambulance, but when I got to the emergency room, they were asking my dad what medications he was taking. Of course my dad told them he wasn’t taking any medications and they believed him! He’s sent to the emergency room from a nursing home and they decide it’s reasonable for him not to be on any medications . . . so of course I corrected him and told them to find the medication list. I don’t know whether the ambulance driver forgot to bring in the list, or gave it to the wrong person, or what, but they couldn’t find it. My dad must be on 12 different medications so I wasn’t sure I could remember them correctly. I called the nursing home and we went over the list with them, and then I gave the handwritten list to the nursing station.