Case Study: Medical Error Kills Hopkins Cancer Patient

Start by providing a short 4-6-line synopsis of the key elements of the case – and discuss what kind of incident occurred (week 1).
In this case, “Medical error kills Hopkins Cancer Patient” by Erika Niedowski, the error was the failure of a planned action to be completed or intended and the use of a wrong plan for instance overdosage of potassium to achieve an aim. These errors were preventable and may not have caused the harm. Preventable adverse drug events and their causes and contributing factors had caused stopped Brianna Cohen's heart. Hence, this is a sentimental event because this unanticipated event resulted in death to a patient, not related to the natural source of the patient's illness. Therefore, the threat and error management model should be used to determine both training needs and organizational strategies to improve the management of threats to safety.
What defenses in the system failed in this case? Can you construct a Swiss cheese analysis of the system defenses and what occurred?
In this case, the James Reason’s “Swiss cheese” analysis illustrates the

After surgery, radiation, chemotherapy and a marrow transplant, an improperly mixed intravenous solution apparently stopped Brianna Cohen's heart. Hence, this case shows that there is an unintended act either of commission or omission, does not achieve its intended outcome, failure of a planned action to be completed for instance an error of education which was the mixed solution, potassium, which caused the heart rhythm to regulate. Furthermore, there was a wrong plan to achieve an error like an error of planning and deviation from the process of care. Therefore, receiving the incorrect medication, or missing a diagnosis that is evident on a lab test or imaging study is a medical