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Improper admission orders resulting in morphine overdose and death

Case Study #1

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 to the actions of the defendant; the 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. She was to be transferred to the co-defendant 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

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.

 

 

Discussion

1.     Summarize the case and the verdict.

2.     Based on your review, do you agree with the court’s decision? Defend/discuss your answer.

3.     What practice-related standard of care issues were breached.

4.     Identify a risk management action plan to prevent this type of issue(s) from reoccurring.


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