Medical Error in a Care Home: Lessons from a Fatal Prescription Mistake

Summary

Even though all hospitals emphasize the need to follow the rules in providing healthcare services to people, mistakes still happen. Regardless of the professionalism of most doctors and nurses, many circumstances, including human factors, can harm the patient. One of the recent medical errors that led to the death of a patient happened in a care home due to a mistake in the drug prescription (Chubb & Williams, 2022).

Description of the Incident

In this case, the nurse Katherine Hutchinson had overdosed using the incorrect medicine that killed Fiona Jayne Thorne, 36 years old, but rather than taking responsibility for her mistake, she attempted to conceal what she had done (Chubb & Williams, 2022). Clozapine was given to Miss Thorne even though it was meant for another patient (Chubb & Williams, 2022). As a result, the patient died, but the unqualified nurse continued to work in the facility, which endangered the lives of other residents (Chubb & Williams, 2022). It allows stating that the ramifications for the nurse whose medical error caused the patient’s death were inadequate.

Consequences for the Patient and Staff

Although Miss Thorne had already passed away, neither CPR nor an ambulance was called, which entirely violated care facility policies. When a patient is discovered unresponsive or unconscious, the nursing home will start CPR and dial an ambulance to arrive (Chubb & Williams, 2022). The rules of the resident’s home suppose that such cases should not happen. However, these interventions are not applied in reality, and nurses without the necessary qualifications work in the healthcare facility. In addition, other nurses ignored the rule to call the emergency, which led to the patient’s death.

Causes and Potential Interventions

The leading cause of this situation is a lack of control over the work of the medical personnel. Improving the supervision of nurses and doctors is vital to avoid such mistakes and ensure that all people working in the facility are qualified for their positions.

Reference

Chubb, J., & Williams, K. (2022). Care home resident died after unqualified nurse administered wrong medication. Mirror. Web.

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StudyCorgi. (2025, October 18). Medical Error in a Care Home: Lessons from a Fatal Prescription Mistake. https://studycorgi.com/medical-error-in-a-care-home-lessons-from-a-fatal-prescription-mistake/

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"Medical Error in a Care Home: Lessons from a Fatal Prescription Mistake." StudyCorgi, 18 Oct. 2025, studycorgi.com/medical-error-in-a-care-home-lessons-from-a-fatal-prescription-mistake/.

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StudyCorgi. (2025) 'Medical Error in a Care Home: Lessons from a Fatal Prescription Mistake'. 18 October.

1. StudyCorgi. "Medical Error in a Care Home: Lessons from a Fatal Prescription Mistake." October 18, 2025. https://studycorgi.com/medical-error-in-a-care-home-lessons-from-a-fatal-prescription-mistake/.


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StudyCorgi. "Medical Error in a Care Home: Lessons from a Fatal Prescription Mistake." October 18, 2025. https://studycorgi.com/medical-error-in-a-care-home-lessons-from-a-fatal-prescription-mistake/.

References

StudyCorgi. 2025. "Medical Error in a Care Home: Lessons from a Fatal Prescription Mistake." October 18, 2025. https://studycorgi.com/medical-error-in-a-care-home-lessons-from-a-fatal-prescription-mistake/.

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