Risk

Assessment
Final Summation

NORTON v. ARGONAUT INSURANCE

COMPANY

Abdulelah Albukhari z
HCIN-630-01-SP21 - Health Care
Law & Risk management

Professor Dorothy O’Hagan

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What happened?

Infant patient dies after a fatal

Lanoxin dose in the hospital
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Background

 After her birth, the patient was diagnosed as having congenital heart disease
Was placed on Lanoxin to strengthen her heart and reduce pulse rate

 Discharged from hospital at two and half months

 Mother administered medicine at home by use of medicine dropper

 Patient was readmitted.

 On January 2, 1960 (Saturday) Dr. Stotler examined the patient As a result of

this examination he concluded that the child needed an increase in the daily
maintenance dose of Lanoxin to 3 c.cs.
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Why is it happening?
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Recommendation:-
order system

Problem

The main issue in this case was the

lack of information in the doctor order

Solution

Implementation and develop the

EHR and CPOE to insure to
minimize the order errors.
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Recommendation:- communication

Problem:-
Poor communication between
the nurse and physician

Solution:-

Implement new protocols that let the

nurse reach the physician or other in
charge physician
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Recommendation:- Policies

Problem

The nurse had not engaged in the

actual clinical practice of nursing for

some time, and she was not ready

Solution

Set policies that make sure not placement not

familiar staff and to minimize the Negligence

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Thank You