Legal Review & Commentary: Teen’s morphine toxicity leads to $400,000 settlement
Teen’s morphine toxicity leads to $400,000 settlement
By Jan J. Gorrie, Esq., and Blake J. Delaney, summer associate
Buchanan Ingersoll Professional Corp., Tampa, FL
News: A 17-year-old female was admitted to a hospital to undergo a breast reduction procedure. While recovering from surgery she received an overdose of morphine, which killed her. The case against the hospital was settled prior to trial for $400,000.
Background: On Dec. 30, the 17-year-old was admitted to the hospital for an elective reduction mammoplasty. The surgery was performed without any complications. During the procedure, she was given 10 mg morphine sulfate IV. In the recovery room, her pain was rated from five to mild, and she received an additional 6 mg morphine for pain.
Shortly thereafter she was taken from the recovery room to the pediatric floor. It was approximately 11 a.m. Nurse H was her primary caregiver and she medicated the patient with 4 mg of morphine sulfate IV at 11 a.m., with repetition of the same dose at 11:45 a.m., 1:15 p.m., and again at 1:45 p.m. An additional 2 mg of morphine was signed out at 2:45 p.m.; but, in her statement, Nurse H indicated this dose was not administered to the patient.
Pain assessments were not performed prior to or after any morphine sulfate injections. At 2:45 p.m., Nurse H assessed the patient and observed that she was sleeping on her stomach and snoring, which is why the morphine was not administered at that time. Around 3:30 p.m., a nurse’s aide went to take the patient’s vital signs and found her blue and without respiration. The patient’s mother, a registered nurse, was at her bedside. Resuscitation efforts were successful; however, she was eventually determined to be brain-dead due to a hypoxic ischemic event. The patient was pronounced dead on Dec. 31.
An autopsy was performed, and the cause of death was determined to be anoxic encephalopathy following respiratory arrest due to morphine toxicity.
Both the Department of Health and the Board of Nursing investigated the case and found negligence. There was also some question as to whether Nurse H took the final vial of morphine home, and whether she returned it to the hospital on Jan. 3. The surviving family brought suit against the hospital claiming negligence. The defendant’s nurse expert opined that the nursing care met the standard of practice, and their anesthesiology expert concurred, stating that the decedent did not die from a morphine overdose.
Nevertheless, the case was settled prior to trial for $400,000.
What this means to you: This case certainly addresses a number of areas of concern for risk management. Nurse H’s actions fell below the expected standard of care in the way she assessed her patient, communicated with other hospital staff, and handled the morphine.
In a medical malpractice case, a breach of duty that was a direct cause of an identifiable injury to a patient constitutes negligence.
"Despite the nursing expert’s opinion that there was no negligence, Nurse H breached a primary duty of care by not having adequately assessed her patient," says Lynn Rosenblatt, CRRN, LHRM, risk manager, HealthSouth Sea Pines Rehabilitation Hospital in Melbourne, FL. Assessment of the patient is a basic tenet in standard nursing practice. "It is a key element in determining the patient’s individualized care plan and any subsequent changes to the plan based on interval assessments."
Although patient assessment is always important, post-surgical patients require a more intensive observation or a higher standard of care during the immediate postoperative period.
"Such issues as wound management, monitoring of the patient’s vital signs, pain management, analgesic medications, and a recognition of the possible adverse complications given the surgery performed are expected. Failure to address these issues breaches the nurse’s duty to the patient," says Rosenblatt.
Specifically designed nursing flowsheets are effective assessment tools for nursing staff caring for post-surgical patients. "This type of documentation provides an easy data entry system that cues staff to the essential elements of care at specific timed intervals that are consistent with standard practices. Furthermore, flowsheets that are completed in their entirety provide excellent case defense at trial," she says.
In addition to Nurse H’s negligence regarding patient assessment, there was also a breakdown in hospital communication. "Effective communication between the recovery room and the floor nurse is essential in evaluating patient status at the time of transfer. This ensures that any changes in the patient condition can be recognized and dealt with in an appropriate and timely manner," says Rosenblatt. Without such contact, it is difficult for the primary caregiver to know what type of care is warranted.
Nurse H should have also been aware of appropriate procedures for dealing with a drug such as morphine. Morphine sulfate is classified as a central nervous system depressant. "Safe administration practices dictate assessment of the patient both before and after administration of this class of medications for the exactly the issue in this case, possible respiratory compromise. A narcotic antagonist and resuscitation equipment should be readily available and the nursing staff should be competent to act with these tools when necessary," says Rosenblatt.
Although it is unclear what the physician’s orders were regarding the morphine, a prudent nurse administering morphine that frequently should have investigated the intent of the physician’s order. "Nurse H possibly should have questioned the pharmacy as to safety, given the drug, the dose, and the time intervals," adds Rosenblatt.
The nursing staff also should have recognized the cumulative effects that analgesics can have with the latent effects of anesthesia in the immediate post-surgical patient. "The patient’s snoring may have been a sign of periods of apnea, particularly in a younger patient. An astute nurse may have attempted to arouse the patient, particularly if the snoring was deep and irregular, as if gasping for breath," says Rosenblatt.
There also is concern about the 2:45 p.m. morphine dose that was not administered. "This would invoke reporting requirements under the Controlled Substances Act of 1970," says Rosenblatt. "If in fact the nurse did violate policy on administration and possession of a controlled substance, there are human resource considerations and possible violations of licensure that may require reporting to the state board of nursing."
The hospital probably acted prudently in settling the case before trial. "Although there were different opinions as to negligence and a serious question as to causation, a jury trial would have likely resulted in a much higher award," says Rosenblatt. "Juries are far more inclined to believe expert testimony from government agencies entrusted with protecting the public’s welfare than from a hired gun who has been substantially paid by the defendant. Also, the fact that this was a wrongful death case involving a minor would have had a negative connotation to a jury. And finally, the testimony relative to possible controlled substances violations and the possibility of an impaired nurse made it clear this case would not present well for the defendant."
The hospital needs to take immediate and effective action to prevent similar situations in the future. In many states, the hospital’s solution can also be coordinated with a state agency responsible for facility oversight. "The facility should conduct an in-depth investigation into all possible issues, including a full root cause analysis with a formal correction plan and a time line for implementation," concludes Rosenblatt.
A 17-year-old female was admitted to a hospital to undergo a breast reduction procedure. While recovering from surgery she received an overdose of morphine, which killed her. The case against the hospital was settled prior to trial for $400,000.
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