Medical malpractice claims may be asserted against any healthcare provider, including nurses. The insured in this case was an early career registered nurse (RN). She began working for a home healthcare agency immediately after receiving her RN license.
Summary
The patient was a 25-year-old female with a complex medical history. She was non-communicative as well as ventilator-dependent and required 24-hour home nursing care. Most recently, the patient was admitted to the hospital for a cardiac evaluation. She was diagnosed with supraventricular tachycardia (SVT) for which antiarrhythmic medications were initiated. Upon discharge from the hospital, the patient returned home with plans to continue receiving 24-hour nursing care provided by the home healthcare agency.
The insured RN in this case began working for the home healthcare agency shortly after receiving her nursing license. The home healthcare agency’s human resources hiring policy required nurses to have six months of experience after becoming licensed before practicing independently in the home. However, due to staffing challenges, the home healthcare agency hired the RN without the requisite six months of experience with an understanding that a supervising nurse would be providing oversight and support, as needed. The agency provided a 5-day orientation, which consisted of an online review of the employee handbook and clinical and operational policies. Upon completing the orientation, the RN was assigned to this patient and was informed that a supervising nurse would be meeting her at the patient’s home to provide support and training.
On the first day of the assignment, the RN arrived at the patient’s home at 8:00 a.m. and received a report from the night nurse. The night nurse stated that the patient had been discharged from the hospital the previous day and that new cardiac medications were prescribed. The supervising nurse arrived shortly after the night nurse left and informed the RN that she could only stay for fifteen minutes as she had her own patient assignment that day. She reviewed the patient’s care plan with the RN but did not discuss the medication administration record (MAR). She then left the home to complete her own patient assignment. After the supervising nurse left, the RN administered the morning medications which included the newly prescribed beta blocker, Nadolol. The MAR listed this medication as Nadolol 20 mg once daily via the gastrostomy tube. (The medication was supplied as an oral suspension containing 10 mg/ml).
Approximately one hour later, the RN observed that the patient was hypotensive and bradycardic. Over the next fifteen minutes, she continued to monitor the patient, and not knowing what to do, called the supervising nurse who advised her to call 911. The patient was then transported to the hospital where she was admitted to the intensive care unit. Despite all life-saving efforts, the patient expired later that evening. The autopsy and postmortem toxicology studies revealed that the patient had received an overdose of the Nadolol.
An internal investigation was conducted by the home healthcare agency’s director which included a retrospective review of the MAR and an interview with the RN and the supervising nurse. It was during the interview and analysis of the patient’s medications that the RN realized that she had erroneously administered 20 milliliters of Nadolol instead of 20 milligrams (2 milliliters).
Risk Management Comments
Six months following the patient’s death, the patient’s mother (plaintiff) filed a lawsuit naming the insured RN and the home healthcare agency. The plaintiff asserted that the RN was not competent to care for a complex patient in the home setting and that she lacked experience and clinical judgement. The plaintiff’s nursing experts opined that the RN failed to adhere to policies, procedures, and/or guidelines regarding safe medication administration. Assertions against the home healthcare agency were focused on improper hiring and supervision with a specific focus on non-adherence to their own hiring protocols precluding independent practice for new graduate nurses. The plaintiff’s nursing experts opined that the home healthcare agency should have had a preceptor program in place.
The RN admitted in her deposition testimony that she had never cared for a ventilator-dependent patient and that she was confused about the medication orders but was hesitant to reach out to anyone as she did not want to jeopardize her new job. Nursing experts for the defense were unable to provide support and opined that the RN should have requested additional orientation and supervision. The RN’s lack of confidence during her deposition further challenged the defense of this case. She contradicted herself on several occasions in her testimony and attributed the error to the fact that she was new to nursing, blaming the home healthcare agency for failing to offer proper onboarding.
Defense experts in cardiology opined on causation, confirming that the cause of death was directly related to the overdose and was not due to the patient’s comorbidities. Although the patient had a limited life expectancy, the defense team concluded that there was a potential for a high jury verdict given the egregious nature of the medication error and the sympathy factor potentially influencing a jury’s decision. Integral to the resolution plan of the defense was the fact that the defense experts were unable to support the care provided by the RN.
Resolution
Based upon the above-referenced defense challenges and diminished potential for a successful defense verdict, a settlement was negotiated in mediation on behalf of the insured RN.
Total Incurred: Greater than $975,000.
(Note: Amounts paid on behalf of other co-defendant(s) named in the case are not available.)
Board Matter
A complaint was also filed by the patient’s mother against the RN with the State Board of Nursing (SBON). The SBON conducted an investigation and concluded that the RN’s actions were in violation of the nurse practice act. A disciplinary action was imposed which included a three-year license suspension and continuing education requirements. Expenses incurred to defend the RN’s license were more than $4,000.
The home healthcare agency was also cited by the department of health for failure to provide appropriate training and supervision to the RN. This case exemplifies the importance of onboarding for early career nurses entering specialty fields. The following recommendations are offered to mitigate risk exposures for early career nurses.
Risk Management Recommendations for Nurses
- Know and comply with your state scope of practice requirements and nurse practice act.
- Pursue ongoing education to remain current in general nursing practice as well as specialty areas of nursing. Self-advocate for a comprehensive orientation or preceptor program upon hire.
- Consider participation in a nurse residency program to address gaps in knowledge and clinical decision-making skills, upon entering into the field as an early career RN or as an experienced RN returning to the field of nursing.
- Proactively seek guidance from a clinical manager, supervisor or preceptor when there is a knowledge deficit and invoke the organization’s chain of command, if additional leadership support is needed.
- Implement the 10 rights of medication administration and ask questions when any medication order is unclear or unfamiliar.
- Incorporate “mindfulness” techniques when administering medications to counteract error-prone human factors related to time pressures such as use of work-arounds and multitasking.
- Utilize evidence-based techniques such as creating distraction-free zones and independent double checks, when applicable to the setting, to optimize nursing workflow in the medication administration process.
Disclaimer
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. 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. All products and services may not be available in all states and may be subject to change without notice. Certain coverages may be provided by a surplus lines insurer. Surplus lines insurers do not generally participate in state guaranty funds, and insureds are therefore not protected by such funds. The claims examples are hypothetical situations based on actual matters. Settlement amounts are approximations. Certain facts and identifying characteristics were changed to protect confidentiality and privacy. “CNA” is a registered trademark of CNA Financial Corporation. Certain CNA Financial Corporation subsidiaries use the “CNA” trademark in connection with insurance underwriting and claims activities. Copyright © 2025 CNA. All rights reserved.
Resources
- Marianne L. Durham, DNP, RN, CPPS, American Nurse Mindfulness for medication safety;, July 4, 2020.“mindfulness” techniques.
- MacDowell P, Cabri A, Davis M. Medication Administration Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
- Munday, Rebecca; Nurse Journal; What is a nurse residency program; Updated May 9, 2024
- Smith, Phyllis; Chain of Command: What nurses need to know; WSNA; January 19, 2023.
- Vera, Matt, The 10 Rights of Drug Administration; Nurseslabs, Updated May 23, 2024.