Ms. Q, aged 28 years, looked down at the prescription in her hand, sighed, and shook her head. It was not the first time she had been confronted with an illegible prescription. In the past eight months since she had taken a job as a nurse practitioner at a mid-size hospital, she had seen plenty of them. 

When she first graduated from school, Ms. Q had accepted a job with a local pediatrician. For the first year the job was an interesting learning experience, but by the third year, she was tired of sore throats and stomach viruses and wanted to experience more challenging clinical work.

Her new position at the hospital certainly provided that. It was much different than working with one pediatrician in a small office. Ms. Q’s current patients had far more serious issues than head colds and stomach flu.
 With the more challenging work came longer hours, more patients, more responsibility and the need to learn the habits and practices of many more physicians. 

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The patient for whom the illegible prescription had been written was Mrs. D, a 72-year-old woman who was on kidney dialysis. Mrs. D’s condition was poor, and she had been admitted to the hospital for the amputation of her right foot. Her nephrologist, Dr. F, had been to see his patient earlier.

Ms. Q walked in while he was writing a prescription for Mrs. D, and the physician interrupted what he was doing to discuss the patient with her. Unbeknownst to Ms. Q, Dr. F had been writing a prescription for 10 millimoles of potassium. However, after Ms. Q left the patient’s room, Dr. F reconsidered the dosage and decided to make it 20 millimoles rather than 10.

Instead of starting with a fresh prescription, or crossing out what he had already written, 
Dr. F attempted to write the number “2” over the number “1,” thereby changing it to 20 millimoles. When he was done, Dr. F left the prescription in the patient’s file for Ms. Q. 

When Ms. Q later returned to the patient’s room, she found the prescription and had trouble making out what it said. Ms. Q took the prescription to the pharmacy, and she and the pharmacist both tried to interpret it.

“I see a 1,” said the pharmacist.

“So do I,” said Ms. Q. “But I also see a 2.”

“I do as well,” said the pharmacist. “What is it with doctors and their handwriting? They should have to take a class.”

They both looked at the prescription for a few minutes more, until Ms. Q said “It says 120.”

The pharmacist agreed that it appeared to be 120 millimoles, and the prescription was filled and administered to Mrs. D. Ms. Q’s shift was over at that point, and she went home. When she returned the next day, she found out that the patient had died.

Both Ms. Q and the pharmacist were suspended from work while the hospital conducted an internal investigation. As part of the investigation, Dr. F was called in to discuss the patient’s death and the circumstances surrounding it. 

“I may have been a little messy when I wrote the prescription,” Dr. F admitted, “but it went through a pharmacist and a nurse before the patient received it. How could the nurse and pharmacist not have realized that a 120-millimole dose of potassium is fatal?”

Both Ms. Q and the pharmacist were asked why they hadn’t contacted Dr. F to clarify what was written, since they had trouble reading his handwriting. Neither practitioner had a good answer. 

“It was after midnight by then,” said Ms. Q. “I did not want to bother Dr. F at that point.”

“Ms. Q and I both agreed that it appeared to both of us to be 120 millimoles,” said the pharmacist. 

The patient’s family hired a plaintiff’s attorney and filed a malpractice lawsuit against the hospital (the employers of 
Ms. Q and the pharmacist) and Dr. F. The hospital’s attorneys met numerous times with Ms. Q and the pharmacist and made them repeat their story several times. Eventually, the hospital’s attorneys suggested to the hospital administrators that it would be in their best interests to settle the case before it reached the trial stage.

The case against the hospital was settled out of court for an undisclosed sum. Both Ms. Q and the pharmacist were terminated from their positions. Dr. F’s case now proceeded to trial. The physician’s attorneys argued that even if Dr. F had erred by writing the prescription sloppily, the nurse and pharmacist should have noticed and called him for clarification. He argued that their superseding error was the cause of the patient’s death.

The jury both agreed and disagreed. After deliberations, the jury found Dr. F negligent, but it also determined that the hospital was 90% at fault, and Dr. F was only 10% at fault. 

Legal background

Because Ms. Q and the pharmacist were hospital employees, the plaintiff’s attorneys opted to sue the hospital, rather than Ms. Q or the pharmacist as individuals. This is quite common. For one thing, a large hospital is going to have deeper pockets than will individual clinicians. Also, as employees of the hospital, their employer bears responsibility for actions carried out while on the job.

Once the hospital settled, the plaintiffs could only try the weaker case against the doctor. While Dr. F had been negligent in his careless writing of the prescription, the acts (or in this case, lack of acts) by the nurse and pharmacist were what allowed the error to reach the patient. Therefore, the jury apportioned the greatest part of the blame for the incident on the nurse and pharmacist.

Had the case gone to trial, the hospital would have been responsible for 90% of the jury’s award. Since it settled out of court (a common occurrence), Dr. F was responsible for only 10% of the fault.

Protecting yourself

Leaving aside the question of why the hospital’s pharmacy software didn’t alert the pharmacist to the fatal dose of potassium, what should have happened is quite clear. 
Ms. Q or the pharmacist should have called Dr. F to have him clarify what was written on the prescription. 

There is absolutely no excuse not to call an attending physician—regardless of the time of day—when there is a question about a patient’s medication. A clinician’s job is to act as the patient’s advocate, and if that means waking a physician with a middle-of-the-night phone call, then so be it.

Guessing what a dosage might be or making a conjecture is completely unacceptable when it comes to patient care. There is never a good excuse for not picking up that phone. Had Ms. Q realized that, she might still have her job, and her patient might still be alive.

Ann Latner, JD, a former criminal defense attorney, is a freelance medical writer in Port Washington, N.Y.