Alleged improper admission orders resulting in morphine overdose and death.

Defendant is a Nurse Practitioner: The decedent patient (plaintiff) was a 72-year-old woman who had been receiving hospital care for acute back pain resulting from a fall. Her past history included chronic pain management and end-stage renal disease for which she received hemodialysis.

Settlement Payment: $0 
Legal Expenses: In excess of $225,000 

 
Note: There were multiple co-defendants in this claim who are not discussed in this scenario. Monetary amounts represent only the payments made on behalf of the nurse practitioner. Any amounts paid on behalf of the co-defendants are not available. While there may have been errors/negligent acts on the part of other defendants, the case, comments, and recommendations are limited 
 
The patient was to be transferred to the codefendant nursing facility for reconditioning and physical therapy prior to returning to her home. The nurse practitioner (defendant) was on-call at the time of the patient’s transfer, and the nursing facility contacted her and read the orders to the defendant nurse practitioner over the telephone. The defendant nurse practitioner questioned the presence of two morphine orders for different dosages with both dosages to be administered twice daily. She instructed the nurse to clarify the correct morphine dosage with the transferring hospital’s pharmacist and to admit the patient only after the pharmacist clarified and approved the morphine orders. The defendant nurse practitioner had no further communication with the facility and no other involvement in the patient’s care. The facility nurse telephoned the hospital pharmacist who approved both morphine orders, and the patient was admitted to the nursing facility. 
 
During the first evening and full day of her nursing facility stay, documentation revealed the patient to be alert and oriented. On the second day, she was found by nursing staff without vital signs. Despite immediate chest compressions and EMS additional resuscitation measures, the patient was pronounced dead. The autopsy results listed the cause of death as morphine intoxication. Surprisingly, the patient also had an elevated blood alcohol level (equal to drinking three to four alcoholic beverages). Because the source of the alcohol could not be identified, the medical examiner was unable to rule out accident, suicide or homicide and classified the manner of death as undetermined.
 

 

Resolution 

Defense experts found the nurse practitioner’s actions to be within the standard of care. 

Defense experts stated that the patient’s final morphine blood levels, even considering her renal disease, could not have resulted from the amount of morphine ordered, administered and recorded in the patient’s health information record. The elevated morphine and alcohol levels led experts to the opinion that the patient may have ingested morphine and alcohol from a source other than the nursing facility. This question was never resolved. 
 
A motion for partial summary judgment for the defendant nurse practitioner was denied by the court and the decision was made to proceed to trial. After the completion of testimony but prior to receiving the verdict the co-defendants settled the case with no liability attributed to the defendant nurse practitioner. This was a successful outcome for the nurse practitioner. 
 

Risk management comments 

The defendant nurse practitioner acted within the standard of care. The nurse practitioner expert indicated that, while she did not depart from the standard of care, the defendant nurse practitioner might have chosen to contact the hospital pharmacist directly to discuss the morphine dosage. 
 

Risk management recommendations 

  • Obtain adequate and pertinent current and past patient clinical information prior to providing patient treatment orders. 
  • Identify and address concerns or questions regarding patient care treatment orders provided by other practitioners and ensure any concerns are resolved prior to accepting the responsibility for the patient’s care. 
  • Communicate urgent or critical patient care concerns to the primary practitioner in a timely manner. 
  • Consult with the collaborating or supervising physician in accordance with state regulations regarding concerns related to patient care issues. 
  • Discuss medication concerns with the involved or consulting pharmacist. 
  • Examine the patient when clinically appropriate and when there is a question about the patient’s condition that requires direct examination, evaluation and intervention. 
  • Document all patient-related discussions, consultations, clinical information and actions taken including any treatment orders provided and ensure that the documentation is timely provided to the primary practitioner. 

 

Guide to sample risk management plan

Risk management is an integral part of a healthcare professional’s standard business practice. Risk management activities include identifying and evaluating risks, followed by implementing the most advantageous methods of reducing or eliminating these risks. A good risk management plan will help you perform these steps quickly and easily.

See the Risk Management Plan created by NSO and CNA. We encourage you to use this as a guide to develop your own risk management plan to meet the specific needs of your healthcare practice.

*CNA HealthPro Nurse Practitioner 2012 Liability Update: A Three-part Approach, CNA Insurance Company, October 2012. Read the complete study.
 
The information, examples and suggestions presented in this material have been developed from sources believed to be reliable, but they should not be construed as legal or other professional advice. CNA accepts no responsibility for the accuracy or completeness of this material and recommends the consultation with competent legal counsel and/or other professional advisors before applying this material in any particular factual situations. Please note that Internet hyperlinks cited herein are active as of the date of publication, but may be subject to change or discontinuation. This material is for illustrative purposes and is not intended to constitute a contract. Please remember that only the relevant insurance policy can provide the actual terms, coverages, amounts, conditions and exclusions for an insured. Use of the term “partnership” and/or “partner” should not be construed to represent a legally binding partnership. All products and services may not be available in all states and may be subject to change without notice. CNA is a registered trademark of CNA Financial Corporation. Copyright © 2017 CNA. All rights reserved. 
 
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