There are several factors that contribute to safety and medication errors within the health care system. Some of the factors that cause these errors are directly attributed to the organizations that are providing healthcare while others are attributed to the medication-use system. In most of the cases multiple factors are involved in these errors (Aspden, Wolcott, Bootman, & Cronenwett, 2007). The case study is an illustration of the complexities within the health care system and the process for medication usage and the inter-related nature of factors that are involved in the provision of quality and safe care (Aspden et al., 2007). The physicians, nurses, and pharmacists of the hospital were not familiar with the treatment of congenital syphilis and had limited knowledge regarding the use of congenital syphilis drugs. The pharmacist that was filling the prescription made consultations with the infant progress notes. In the notes the nurse practitioner documented a recommendation for treatment for the health department (Aspden, Wolcott, Bootman, & Cronenwett, 2007).
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