As the on-call nurse practitioner for a physician practice that specializes in nursing facilities, Ms. N, aged 42 years, was often the one who was called to verify medication orders when a patient was being transferred from the hospital to the nursing home. It was a responsibility Ms. N took seriously, listening carefully and questioning anything unusual. 


One weekend when she was on call, she received a typical phone call from a nursing facility. The 73-year-old patient, Mrs. R, had been in the hospital receiving care for acute back pain that occurred as a result of a fall. Mrs. R’s history included chronic pain management and end-stage renal disease, for which she received hemodialysis.

The patient was being transferred to the nursing facility for recovery and physical therapy before returning to her home. As usual, a member of the nursing facility’s staff read Ms. N the medication orders for her approval prior to the transfer. Ms. N immediately noticed a problem. 


“You have two different orders for morphine, for different doses, with both being administered twice a day,” Ms. N told the nursing facility staff. “This does not sound right.” 


Ms. N told the nursing facility staff that they must clarify the correct morphine dosage with the transferring hospital’s pharmacist, emphasizing that only after the pharmacist had clarified and approved the morphine orders should they admit the patient. Ms. N had no further contact with the nursing facility about the patient, and was not involved in the patient’s care. Because of this, Ms. N was unaware of the cascade of events that would cause her to be named as a defendant in a medical malpractice lawsuit.