Ms. K had recently graduated nursing school. She had hoped to find a job in a pediatrician’s office but ended up with a higher paying though less interesting position in a rehabilitation center.

Her plan was to remain at this job until she paid off her student loans, and then move on to something more in line with her original goal. Little did Ms. K know that her first year in practice would be marred by a mistake that would haunt her for the next several years.


Mrs. O, aged 55 years, had been sent from the hospital to the rehab center for a one-week stay following foot surgery. Ms. K was on duty when Mrs. O arrived. After Mrs. O was settled in her room, Ms. K made sure that the order for the patient’s pain medication had been sent to the institution’s pharmacy. This is where the trouble began.


Unbeknownst to Ms. K, the patient’s physician had mistakenly written a prescription for morphine. The physician intended to write the prescription for 50 mg of intramuscular meperidine (Demerol) but incorrectly wrote the order for morphine instead. While the dose was appropriate for Demerol, it was excessive for morphine.


The pharmacist called Ms. K to express concern about the prescription, indicating that the dosage was unusually high for morphine. He added that the pharmacy did not even have that amount of morphine on hand. 


The rehab center’s policy was that in an event such as this, the nurse should contact the physician to double-check the medication order, but Ms. K was inexperienced and instead of contacting the doctor, she contacted the rehab center’s administrative office. An administrator gave 
Ms. K permission to give Mrs. O the morphine.

Ms. K, several other nurses, and the pharmacist all had to scour the facility to come up with the dose prescribed. The entire supply of morphine from the pharmacy as well as from emergency kits on the patient-care floors was combined into a single 30-mg dose that was given to the patient. The process of collecting the morphine and getting approval had taken a long time, and Ms. K’s shift was over. She left without charting the dose or monitoring the patient’s respiratory status.


That night, the nurses on duty noticed signs of respiratory depression in the patient but did not report it to the attending physician. At about 6 a.m. the next day, Mrs. O was found unresponsive with pinpoint pupils and barely breathing. She was taken by ambulance to the hospital, and numerous doses of naloxone were given on the way.

At the hospital, it was discovered that Mrs. O had suffered a mild heart attack and was in renal failure due to the lack of oxygen from narcotic-related respiratory depression. She ultimately suffered brain damage and spent six months in the hospital relearning how to walk, talk, eat and groom herself. She will need 24-hour supervision to assist with daily activities for the rest of her life.


When Ms. K heard about what had happened to the patient, she was stricken with guilt and remorse. Every employee in the rehab center was discussing the situation, and Ms. K felt that people were talking about her behind her back, despite the fact that many of those same nurses had taken part in helping put together the dose of morphine. 


After Mrs. O was released from the hospital, her husband sought the counsel of a plaintiff’s attorney to assess whether they might have grounds for a lawsuit. After hearing the story and reviewing the medical records, the attorney informed them that they definitely had a case against both the physician and the rehab center.


When the rehab center was notified about the impending lawsuit, the administrator called Ms. K into her office and advised her that although she wasn’t personally being sued, she and several of the other nurses, as well as the administrator herself, would certainly be called to testify. Ms. K was advised to speak to the rehab center’s defense attorney.


With great trepidation, Ms. K met with the attorney, who explained the legal process to her. He told her that she would probably have to testify at both a deposition and at trial, if the case went that far, and that it was important that her story be the same each time. 


Ms. K testified that the pharmacist told her that the dose of morphine was high, and that she had contacted administration for approval before giving the patient the medication. When questioned by the plaintiff’s attorney, Ms. K was forced to report that she knew the dose was high and could cause respiratory distress. She was embarrassed to admit that she had rushed home before charting the information, thinking that she could just do it the next day. 


After two days of deliberations, the jury awarded $3.2 million to Mrs. O and her husband. The jurors found the rehab center liable for neglect and the center and the physician liable for negligence. 


Legal background


As part of the verdict, the jurors also had to apportion liability among the parties involved. In cases in which there are multiple defendants, it is common for the judge or jury to apportion the guilt according to who was most at fault.

Although it was the physician who made the original mistake, the rehab center was held most responsible because the order could have (and should have) been questioned before the medication was administered to the patient. The jurors found the rehab center to be 90% liable and the physician to be 10% liable.


Protecting yourself


Any clinician who has a question as to whether a medication or dose is appropriate should ask the prescribing physician. Ms. K’s first mistake was that she did not follow the rehab center’s policy and call the physician; instead, she sought approval from an administrator.

Ms. K’s second mistake was that she did not chart the dose or check the patient for respiratory depression — even though she was aware that the dose was unusually high and that morphine can cause respiratory depression. Not charting this information also meant that the staff on the next shift was not fully informed about the situation.

Sadly, this case demonstrated failures on many levels. The pharmacist’s warning was ignored. Several nurses were involved in pooling together a dose of medication that clearly should have set off alarm bells for many of the clinicians. Yet despite all this, no one bothered to consult the prescribing physician.


Perhaps as a clinician new to the practice, Ms. K was embarrassed to question the medication order of a supervising physician. However, picking up the phone would have protected the physician, the rehab center, Ms. K, and most important, the patient. Never be afraid to ask a question. It could make a world of difference.