Nurse Medical Malpractice Case Study with Risk Management Strategies
Presented by CNA and NSO
Medical malpractice claims may be asserted against any healthcare practitioner, including registered nurses (RNs). This case study involves an RN working in a home healthcare setting.
The insured registered nurse (RN) was working for a home healthcare agency. The RN was caring for a 19-year-old female patient who was essentially unresponsive due to malignant neoplasm of multiple sites of her brain. These sites were initially diagnosed when she was 15 years old and resulted in multiple surgical and chemotherapeutic treatments.
The patient was neurologically devastated, non-communicative, had a tracheotomy, and was ventilator dependent. The patient’s prior medical history was extensive and included diabetes mellitus type I, epilepsy/seizures, kidney disease, bowel/bladder incontinence, cortical blindness, dysphagia, contractures, convulsions, central sleep apnea, paralysis of vocal cords and larynx, obstructive hydrocephalus, hypothyroidism, panhypopituitarism and adrenal disorder.
Most recently, the patient was admitted to the hospital after experiencing atrial flutter and cardiac arrest at home but recovered and had mostly returned to baseline. During her hospital admission, she was placed on Nadolol (a beta blocker) 30 mg twice a day (BID) and Flecainide (an anti-arrhythmic) 25 mg (1.3 mL) BID via gastrostomy tube (G-tube). At discharge, the hospitalist ordered her to wear a transtelephonic Holter monitor to evaluate any additional arrhythmias.
Upon discharge from the hospital, the patient was admitted to the home healthcare agency for 24-hour continuous home nursing care. During the home healthcare admission, the mother (patient’s guardian) changed the patient’s code status from a Do Not Resuscitate (DNR) to a Full Code. The mother’s rationale for updating the patient’s code status was her belief that her daughter was now medically stable and had been cancer-free for almost a year. The code status was changed despite the mother being told during the previous hospital admission that the patient’s life expectancy would be less than six months. The home healthcare agency’s admission assessment, completed by the clinical supervisor, noted the patient’s rehabilitation potential to be “poor” and that her overall prognosis was “poor” as well.
The insured RN reported to the patient’s home the morning following the patient’s admission to home healthcare. The RN had cared for the patient previously and was familiar with her medications and daily routines. Prior to starting his shift, the night nurse gave him a report on the patient’s current status and the updated plan of care, including the new medications.
The RN correctly noted the new medication orders for Nadolol 10 mg BID and Flecainide 25 mg (1.3 mL) BID via G-tube. At 8:00 a.m., the RN administered routine medications to the patient and performed her morning care. Between 9:45 a.m. and 11:45 a.m., the RN continued to provide routine patient care. At 12:00 p.m., the RN administered Flecainide and Nadolol, as well as other routine medications. However, instead of administering 25 mg (1.3 mL) of Flecainide as ordered, he administered 25 mL, which was approximately 19 times the prescribed dosage.
At approximately 2:00 p.m., the RN identified changes in the patient’s heart rate and vital signs. He noted that the patient was bradycardic with a weak pulse and unable to be aroused. The RN called the patient’s mother at work to report the changes in her condition. The mother advised him to call the patient’s cardiologist about the change. The RN contacted the cardiologist and was advised to call 911 for an ambulance to take her to the emergency department (ED).
When the ambulance arrived, the RN gave a brief report of the patient’s medical history and the medications he had given the patient that morning, which included Flecainide 1.3 mL. At this time, the RN realized that he had administered the incorrect dosage. The RN called the patient’s mother and advised her of the medication error (administering 25 mL of Flecainide instead of 1.3 mL). The RN proceeded to the ED and arrived approximately 10 minutes after the ambulance. The RN informed the ED providers of the medication error, and a serum toxicology test was ordered to confirm the error. The patient was admitted to the intensive care unit, and despite all life-saving efforts, she died soon thereafter.
Following the patient’s death, the mother (plaintiff) filed a lawsuit against the insured RN and the home healthcare agency. The allegations against the RN included:
- Failure to properly administer the correct and prescribed dosage of Flecainide to the patient and a conscious disregard of the known risk of Flecainide toxicity and overdose;
- Administering an improper, excessive dose of Flecainide medication in an amount more than 19 times the prescribed dosage and with a conscious disregard of the known risk of Flecainide toxicity and overdose;
- Failure to review, confirm and/or adhere to the prescribed documentation regarding the medications;
- Failing to confirm and/or verify the correct dosage of Flecainide that was prescribed to be administered to the patient; and
- Failure to adhere to proper policies, procedures, and/or guidelines regarding the administration of prescribed medications to the patient.
Risk Management Comments
The cardiology expert for the defense opined that the life expectancy of the patient was six months or less due to her severe hemodynamic instability. The defense’s neuro-oncology expert testified that there was no chance for the patient’s full recovery due to the extensive treatment of her metastatic cancer and estimated that the patient’s life expectancy was much less than six months.
Irrespective of the patient’s life expectancy, it was determined that defense of the RN would be difficult due to the egregious nature of the medication error.
An additional concern arose that the RN was a poor witness at his deposition. Despite being prepared by the defense team, the RN lacked confidence during his testimony and contradicted himself many times. At one point in the deposition, the RN testified to knowing that he was administering an excessive amount of Flecainide, but proceeded to do so anyway.
The plaintiff was represented by a high-powered and aggressive law firm. The defense believed that when a jury learned of the RN’s disregard of medication safety, they may choose to award a large verdict to the plaintiff for the emotional loss of a beloved daughter, despite the patient’s pre-existing, severe condition. Therefore, the decision was made to settle the case on behalf of the insured RN.
The indemnity payment and legal expenses totaled more than $1,000,000.
(Monetary amounts represent the expenses made solely on behalf of the individually insured RN and do not reflect payments made on behalf of any other parties who may have been involved in the claim. Amounts paid on behalf of other co-defendants named in the case are not available.)
Risk Control Recommendations
Medication safety has become a highly prominent issue, as national patient safety initiatives focus upon practitioners’ attention regarding the necessity to improve medication management and error reporting processes. However, dispensing and administration lapses, which are often difficult to defend in the event of a malpractice claim, continue to occur. By following the suggested actions, among others, nurses can assist in reducing the liability associated with medication errors:
- Follow established medication protocols. If “work-arounds” persist, consult with the facility’s nursing leadership about opportunities to improve medication protocols and systems, and methods to enhance staff monitoring and compliance.
- Understand that while bar-code scanning can reduce medication errors, this and other medication safety methods are not foolproof. Consistently verify the “six rights” when administering medications to patients:
- Right patient;
- Right drug;
- Right dose;
- Right route;
- Right time; and
- Right documentation
- Know the medication(s) being administered to the patient. While nurses do not prescribe, and only rarely dispense medications, they are responsible for administration. Nurses are the last line of defense to prevent medication errors from reaching the patient. Therefore, they must understand why the patient is taking a particular medication, as well as interactions, side effects, or adverse reactions that may occur.
Medication administration errors represent a significant concern, especially in high stress/high patient acuity locations. Whether in an acute care facility or their own home, patients have the right to safe care. For this reason, nurses must be cognizant of the medications they are administering, their side effects, and the potential drug-to-drug interactions.
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.