When Ms. N hung up the phone, the nursing facility did contact the transferring hospital’s pharmacist. The pharmacist approved both orders, and the patient was transferred to the nursing home, where she was given the medication. For the first evening and full day of her stay at the nursing facility, Mrs. R was documented as being alert and oriented.

On the second day, nursing staff found her in bed without vital signs and attempted to resuscitate her without success. Mrs. R was pronounced dead, and an autopsy found that the cause of death was morphine intoxication. 

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The distraught family of Mrs. R sought the advice of a plaintiff’s attorney who told them that he believed that they had a good case and filed a medical malpractice lawsuit, naming numerous defendants, including the nursing facility, the hospital, the pharmacist, the physicians, and Ms. N. 

Surprised that she would be included, Ms. N immediately consulted with a defense attorney, telling him that she was the one who spotted the problem. The attorney explained that it was common in cases such as this for anyone even tangentially involved to be sued, but that he had every reason to believe that he could have the lawsuit dismissed against her. Unfortunately, this did not prove to be the situation. Although the defense attorney filed a motion to dismiss the lawsuit against Ms. N, the court denied the motion, and the case proceeded to trial. 

At trial, a nurse practitioner expert testified that Ms. N had acted appropriately and did not violate the standard of care owed to the patient, stating that she had recognized the potential problem and notified the nursing home not to accept the patient until the issue had been resolved.

The plaintiff’s attorney, on cross-examination, asked the expert whether she thought Ms. N could have done anything more. The expert answered that while Ms. N did not depart from the standard of care, she might have chosen to contact the hospital pharmacist directly to clarify the morphine dosage. 

Because of the many codefendants, the trial continued for days. After all of the testimony was heard, but before the jury was sent to deliberate, the other codefendants settled the case with the plaintiff, and the case against Ms. N was dismissed.