In a reported case out of California, a 33-year-old male presented at his hospital’s ED with severe abdominal pain. He was diagnosed with appendicitis and admitted for an appendectomy. During the first postsurgical hour, IV Demerol was initiated in the postanesthesia recovery unit, starting with 100 mg in divided doses. (Confidential v. Confidential, Superior Court, Riverside County, Calif., January 17, 2008)
The patient was then transferred to a med/surg unit where the Demerol was continued and he was placed on a liquid diet.
Two days after surgery, the man’s physician wrote an order for two tablets of Vicodin orally for pain, as needed. The physician did not cancel or otherwise change the IV Demerol order. At this point, the patient had received a total of 675 mg of Demerol since he first came out of surgery. (Medication Mix-Up: Nurses Continue Demerol IV, Post-Appendectomy, Patient Seizes, Dies,” Legal Eagle Eye Newsletter for the Nursing Profession, June 2008)
Because the patient continued to have significant pain, the nurse caring for him when the Vicodin order was written believed that the patient could not take the pain medication orally since he was still on a liquid diet. Nurses on subsequent shifts followed this rationale as well.
However, on the third postoperative day, the patient’s evening nurse informed the physician that the patient was still having severe pain and gave him the Vicodin. The patient informed the nurse that the pills were not working. She consulted with her nurse manager and afterward gave the patient more IV Demerol.
The next afternoon, the same nurse found the patient unresponsive and thought he was having a seizure. A code was called but was unsuccessful. The cause of death was acute meperidine toxicity with an enlarged heart as a contributing factor.
The family filed a lawsuit alleging wrongful death. The Superior Court, Riverside County, Calif., opined that the “nurses at the hospital made the decision to continue the patient’s IV Demerol … even though the physician had written new orders for oral Vicodin.” The court mentions the physician neglected to discontinue the Demerol expressly when the order for Vicodin was written.
The case reportedly settled for $3,500,000.
This case illustrates how disastrous a medication error can be. Not only was there one instance of an error, but there were several that compounded the initial one and led to the patient’s death.
The physician played a pivotal role in this case by not discontinuing or otherwise modifying the IV Demerol order. Even so, it was the nurses’ obligation to clarify the fact that there were two orders for pain for this patient.
As nurses know, they are the last line of defense for the patient. Questioning a physician or other healthcare provider’s order when you are uncertain about it is vital in protecting the patient’s well-being.
Utilizing resources available to you when you are in doubt about an order also is important. Interestingly, in this case, one of the nurses discussed the patient’s pain level — that the Vicodin pills were not working, according to the patient — with her nurse manager. What was actually discussed is not known. But what is known is that the nurse then gave the patient more IV Demerol.
It apparently did not occur to the nurses why the pain medications were not working. Although one nurse told the physician the patient was having severe abdominal pain on the third postoperative day, neither the physician nor the nurse further assessed the patient. Was the patient experiencing pain from a cause other than postsurgical pain? Was there another medical issue that developed postsurgically?
This case illustrates that you can never treat medication administration as a routine obligation. It requires you to be vigilant, ever-present and guard your patient’s life like you would your own.
Nancy Brent’s posts are designed for educational purposes only and are not to be taken as specific legal or other advice. Individuals who need advice on a specific incident or work situation should contact a nurse attorney or attorney in their state. Visit The American Association of Nurse Attorneys website to search its attorney referral database by state.