Legal Review & Commentary

Malfunction leads to a death: $1.5 million verdict

By Mark K. Delegal, Esq., and Jan Gorrie, Esq. Pennington, Moore, Wilkinson, Bell, and Dunbar, PA, Tallahassee, FL

News: Following a patient’s successful surgery, his morphine pump overmedicated him, causing cardiac arrest. The Code Blue cart at the scene was missing two critical pieces of equipment, which resulted in a delay in care and, ultimately, brain damage and death. A Missouri jury returned a $1.5 million verdict against the hospital.

Background: A 34-year-old police officer came to the hospital for elective lower back surgery to repair a ruptured disc. The surgery was a success. After surgery, the patient was placed on a self-dosing morphine pump. The pump was designed to allow the patient to self-administer morphine up to a specified limit as needed for pain and discomfort. The pump was programmed to deliver a maximum amount and no more, regardless of how many times the patient pushed the button.

Over the next 15 hours, he received 81 mg of morphine. While this is a healthy dose of morphine, it was not necessarily excessive. Over the same period, his oxygen saturation was not monitored and, allegedly, he had snored on and off throughout the night, which for him was unusual.

The morning after surgery, the patient was found in respiratory arrest. A Code Blue was called. The code team responded with the crash cart, but two pieces of critical equipment were missing from the cart — the Ambu bag and a backboard. The medical records indicated there was a six-minute delay from the time the code team realized the Ambu bag was missing and the time the patient was properly ventilated. A replacement backboard was retrieved in a similar time frame as the Ambu bag. The patient suffered severe brain damage and was pronounced dead that afternoon.

The plaintiff maintained that the patient was not appropriately monitored after surgery for signs of respiratory arrest and that his abnormal snoring should not have been dismissed. The plaintiff also claimed the hospital failed to ensure that proper equipment was on the crash cart.

The hospital countered that, despite the medical record notation, the response time to obtain the replacement equipment was only two to three minutes. A jury found the hospital at fault and awarded $1.5 million to be divided among the decedent’s wife, three sons, and parents. The verdict has been appealed by the hospital.

What this means to you: Under the described chain of failures, it is interesting that this case was not settled prior to trial, particularly given the age and underlying condition of the patient as well as his vocation.

"An unexpected outcome of this magnitude on a young patient who entered the hospital for an elective procedure is devastating to the staff, particularly if there were policies and procedures that were not followed," notes Lynda Nemeth, RN, MS, JD, administrative director of quality and risk management for Norwalk (CT) Hospital.

"Generally, when a patient is on an automated pump that delivers analgesia, several safety factors are in place," she explains. "The pumps have delivery parameters and should have fail-safe mechanisms to prevent a bolus of medication to the patient. While it appears the 81 mg of morphine was not considered an overdose, was within the prescribed amount, and was not the result of machinery malfunction, there should have been clear guidelines for the monitoring of a patient on a patient-controlled analgesia pump.

"Minimally, vital signs should have been taken once a shift on a post-op patient. Whether this would include pulse-oximetry readings or blood gases would be a judgment call of the attending physician and bedside nursing staff as to necessity.

"As for the patient’s snoring, even though there was no history of such, it would not be considered unusual for a patient to snore while asleep and doubtful if nursing staff would routinely check a patient’s history as to snoring. It is not a standard question asked during the nursing assessment," Nemeth says.

Prior to code teams and code-card setups that included Ambu bags and backboards, patients found in cardiac arrest were resuscitated by putting them on a hard surface (the floor) and giving mouth-to-mouth resuscitation. Staff trained in basic life support, which is a requirement from the Joint Commission on Accreditation of Healthcare Organizations, are instructed in resuscitation.

"A code team, properly trained, should take immediate resuscitative actions and should not wait for missing equipment when other options are available," she says. "Further, in a code team response there should be a designated recorder whose responsibility would be to ensure accurate documentation of the time that code was called, response time of the code team, start time of the resuscitative efforts, medications and treatments given, and the time when efforts were discontinued because of a successful resuscitation or death.

"There should also be a check of the equipment and operational status of each code cart, minimally once every 24 hours and in high-risk/high-use areas, once a shift. Unfortunately, in this instance, once there was apparent failure in one system, it was followed by failure in another," she concludes.


Lisa Philpott vs. St. Luke’s Hospital of Kansas and Reliable Health Care Inc., Jackson County (MO) Circuit Court, Case No. 98-CV-18845.