Nurse License Protection Case Study: Administering medication without an order

Nurses and License Protection Case Study with Risk Management Strategies

Presented by NSO

A State Board of Nursing (SBON) complaint may be filed against a nurse by a patient, colleague, employer, and/or other regulatory agency, such as the Department of Health. Complaints are subsequently investigated by the SBON in order to ensure that licensed nurses are practicing safely, professionally, and ethically. SBON investigations can lead to outcomes ranging from no action against the nurse to revocation of the nurse’s license to practice. This case study involves a registered nurse (RN) who was working as the clinical director of a small, rural emergency care center.


The insured RN was employed as the clinical director of a small, rural emergency care center when they responded to a Code Blue, arriving just as the patient was being intubated. The patient was fighting the intubation, so a physician gave a verbal order for propofol. The RN asked the pharmacy technician to withdraw a 100-cc bottle of propofol from the medication dispensing machine and asked another nurse to administer the medication to the patient. Shortly after the other nurse began administering the propofol, the patient’s blood pressure dropped, so the nurse was ordered to stop the propofol infusion.

The patient continued to decompensate and suffered respiratory collapse/arrest. Following some delay, the patient was eventually intubated, then emergently transferred to a higher acuity hospital for further treatment. The patient ultimately suffered anoxic encephalopathy while he was in respiratory arrest.

A recorder was present documenting the Code, and, afterwards, another nurse transcribed the recorder’s notes into the patient’s healthcare information record. The recorder noted that it was the insured RN who advised the pharmacy technician to remove propofol from the medication dispensing machine and instructed a nurse to administer the medication. However, the recorder failed to note that the physician gave a verbal order for the propofol. The insured RN failed to review the notes that the recorder and nurse entered into the patient’s healthcare information record and failed to note this error. The physician who was present during the Code also failed to catch this error in the record.

Approximately six months later, the patient’s family filed a lawsuit against the emergency care center. During a review of the Code record in response to the lawsuit, it was noted that, during the Code, the RN instructed another nurse to administer propofol. However, there wasn’t any indication in the record that a physician had ordered the medication. The emergency care center dismissed the RN from employment and reported the incident to the SBON. The SBON opened its own investigation into the RN’s conduct.



While the insured RN denied ordering another nurse to administer propofol without a verbal order from the physician, the RN could not deny failing to ensure that the propofol administration was documented in the patient's healthcare information record.


The RN entered into a stipulation agreement with the SBON, under which:

  • the RN’s multi-state licensure privileges were revoked;
  • the RN was required to complete coursework on nursing jurisprudence and ethics, medication administration, documentation, and professional accountability; and
  • the RN was required to work under direct supervision for one year and submit quarterly nursing performance evaluations to the SBON.

The total incurred expenses to defend the insured RN in this case exceeded $16,600.


Risk Control Recommendations

  • Know the parameters of your state’s nursing scope of practice act, and your facility’s policies and procedures, related to medication administration. 
  • Only accept verbal drug orders from practitioners during emergencies or sterile procedures. Before carrying out a verbal order, repeat it back to the prescriber. During a Code Blue, be sure to communicate all procedures, medications, treatments to the recorder.
  • Review Code Blue records for completeness and process of care after each Code. Report any concerns and provide feedback through proper channels to ensure that any errors in the record or areas of improvement are identified and addressed.
  • Document simultaneously with medication administration, whenever possible, in order to prevent critical gaps or oversights.




These are illustrations of actual claims that were managed by the CNA insurance companies.  However, every claim arises out of its own unique set of facts which must be considered within the context of applicable state and federal laws and regulations, as well as the specific terms, conditions and exclusions of each insurance policy, their forms, and optional coverages. The information contained herein is not intended to establish any standard of care, serve as professional advice or address the circumstances of any specific entity. These statements do not constitute a risk management directive from CNA. No organization or individual should act upon this information without appropriate professional advice, including advice of legal counsel, given after a thorough examination of the individual situation, encompassing a review of relevant facts, laws and regulations. CNA assumes no responsibility for the consequences of the use or nonuse of this information.

This publication is intended to inform Affinity Insurance Services, Inc., customers of potential liability in their practice. This information is provided for general informational purposes only and is not intended to provide individualized guidance. All descriptions, summaries or highlights of coverage are for general informational purposes only and do not amend, alter or modify the actual terms or conditions of any insurance policy. Coverage is governed only by the terms and conditions of the relevant policy. Any references to non-Aon, AIS, NSO, NSO websites are provided solely for convenience, and Aon, AIS, NSO and NSO disclaims any responsibility with respect to such websites. This information is not intended to offer legal advice or to establish appropriate or acceptable standards of professional conduct. Readers should consult with a lawyer if they have specific concerns. Neither Affinity Insurance Services, Inc., NSO, nor CNA assumes any liability for how this information is applied in practice or for the accuracy of this information.

Nurses Service Organization is a registered trade name of Affinity Insurance Services, Inc., a licensed producer in all states (TX 13695); (AR 100106022); in CA, MN, AIS Affinity Insurance Agency, Inc. (CA 0795465); in OK, AIS Affinity Insurance Services, Inc.; in CA, Aon Affinity Insurance Services, Inc., (CA 0G94493), Aon Direct Insurance Administrators and Berkely Insurance Agency and in NY, AIS Affinity Insurance Agency.


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