Legal Review & Commenatary

Failure to administer medication leads to death

Prescription order sheet misplaced, $976,784 verdict

News: An elderly man was transferred to a nursing home following a brief stay at another facility. Although the man was currently taking more than 20 medications, the second page of the two-page prescription order sheet somehow was misplaced during the transfer. The second nursing home did not realize the mistake and accordingly failed to give the patient all of his necessary medications. The man subsequently experienced acute renal failure and died. The man's estate sued the first facility, the second facility's medical director, and the employer of the second facility's nurses. A defense verdict was returned for the first facility, but a jury awarded the plaintiff $976,784 against the other two defendants.

Background: A 70-year-old man underwent a bilateral below-knee amputation. Following his stay at the hospital, he was transferred to a nursing home with a list of more than 20 medications he was taking, including three customary immunosuppressants. After about a month at the nursing home, he was transferred to another long-term care facility. The first nursing home sent the hospital discharge summary and prescription order sheet to the second nursing home, but only the first page of the two-page prescription order sheet was received.

Despite a note at the bottom of the prescription order sheet to "see page 2," the second nursing home's medical director and one of its nurse practitioners failed to notice the discrepancy between the discharge summary medication list and the first page of the prescription order sheet. As a result, the second nursing home ordered only those medications listed on the first page of the sheet, including only one of the three immunosuppressant drugs. The other two immunosuppressants were necessary because the patient had undergone a kidney transplant 4½ years earlier.

Within 3½ months at the second nursing home, the man began rejecting his kidney, even though he had had excellent renal function at the hospital and at the first nursing home. He subsequently suffered acute renal failure requiring dialysis, and he ultimately died.

The man's estate sued the first nursing facility, the second nursing facility's medical director, and the employer of the nurse practitioner employed by the second facility. The first facility defended the suit by arguing that both pages of the prescription order sheet had been sent to the second facility. The medical director argued that a nurse at the second facility should have followed up on the discrepancy. All defendants tried to limit their exposure by maintaining that the man would have died within one or two years even if all of the medications had been administered.

A jury found in favor of the first nursing facility but returned a verdict in favor of the plaintiff for $976,784 against the medical director and the nurse practitioner's employer.

What this means to you: "One of The Joint Commission's National Patient Safety Goals for 2007 for all accreditation settings is medication reconciliation, which refers to the practice of comparing current and future medication orders against the patient's past dosing history," says Lynn Rosenblatt, CRRN, LHRM, risk manager at HealthSouth Sea Pines Rehabilitation Hospital in Melbourne, FL. Based on years of survey activity and data collection related to medication errors, The Joint Commission has focused on a very significant flaw in the ongoing care of patients.

No matter the setting — whether the physician's office, home health agency, ambulatory surgery, hospitals, nursing homes, and even in the emergency department — the need to know which medications the patient has been taking is an essential element for safe care. According to Rosenblatt, practitioners in all settings should question the patient and/or the patient's representative or family to establish a verifiable list of medications taken at home. The list should include not only daily prescription meds, but those taken infrequently and even over-the-counter and herbal remedies.

Providers should train the clinical staff to ask questions, but most importantly to think "out of the box." Frequently, it is not the medications that are normally associated with the admitting diagnosis, but those that are taken for a chronic condition that are not picked up when the patient is admitted or transferred between services or providers. This is particularly true for post-surgical patients where medications are stopped or held prior to surgery and never restarted.

In this case, the patient would most likely have been suffering from diabetes or peripheral vascular disease, or perhaps both, as these conditions frequently result in amputations. An astute nurse also would consider such issues as dialysis or renal transplant. In this case, a patient being on one immunosuppressant should have triggered an inquiry about others, as transplant patients rarely take only one of these medications.

Second page apparently overlooked

According to Rosenblatt, another factor in this case was that the prescription order sheet directed the reader to a second page, which apparently was overlooked during the admission to the second nursing home. From that point forward, it appears that the patient received only a portion of his life-sustaining medications. This is just the issue that the National Patient Safety Goal addresses.

"Past history of serious adverse medication errors have prompted closer scrutiny of how medications are ordered, modified, and discontinued," says Rosenblatt. In many health care facilities, particularly low profit-margin establishments such as long-term care homes, the act of transcribing orders is arduous and prone to error. Many smaller hospitals and nursing homes lack sophisticated computer software to reduce transcription error. There often is a single nurse who transcribes physician orders solely from a multi-form order sheet to a manually written Medication Administration Record (MAR).

When such problem-prone processes are combined with poor practice or, as in this case, negligence, the result is bound to pose a serious safety risk to the patient and a liability to the provider. The nurse practitioner admitting the patient at the second nursing home committed a major omission when he or she failed to reconcile all available information before writing orders. The medical director, who is the overseer of lower-tier practitioners such as advance practice nurses, was negligent because he or she failed to provide the supervision that his position requires.

It may be entirely possible that the admissions orders were transcribed by a desk nurse from the single prescription order sheet that was received. He or she in turn called the nurse practitioner and conveyed by phone the transcribed medication list. Any correlation to the discharge summary would have been moot at this point. The desk nurse then would have been given a verbal order to approve the list, and the orders then would have been transcribed to the MAR for administration.

Conceivably, it could have been some time before the advanced practice nurse actually saw the patient. In fact, it appears doubtful if he or she ever compared the original transcribed orders to the prescription order sheet to assure accuracy. Taking that premise a step further, it is unlikely that the nurse practitioner ever compared the admission orders to the discharge summary.

It is for these reasons that The Joint Commission frowns on any medication ordering process that does not include the input of the patient and/or family and does not have system of checks and balances to assure greater accuracy. Asking a patient or family what a patient routinely takes is one way to ensure that a transfer medication packet is complete. While patients and families do not always know the exact names of medications that a patient takes, they frequently know that the patient takes something for one condition and something else for another.

Nurses admitting patients are another source of verification. Going over a patient's past medical history is essential to a complete nursing assessment. It is good nursing practice. Had the staff nurse compared the discharge summary to the single-page order sheet, he/she would have realized that some medications were lacking. The patient's previous transplant history should have triggered questions during the admission assessment. The nurse practitioner is equally as responsible for not reaching a similar conclusion during the visual history and physical.


  • Tazewell County (IL) Circuit Court, Case No. 02-L-96.