Ramifications of medication errors and how to prevent them

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.

 Take the webinar, “Eagle Eye: Exercises in Reducing Medication Errors” to learn more.

About the Author:

Our legal information columnist Nancy J. Brent, MS, JD, RN, concentrates her solo law practice in health law and legal representation, consultation, and education for healthcare professionals, school of nursing faculty and healthcare delivery facilities. Brent has conducted many seminars on legal issues and has published extensively in the area of law and nursing practice. She brings more than 40 years of experience to her role of legal information columnist. Her 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. 


  1. Debbie Stevens January 5, 2017 at 8:50 am - Reply

    I also wonder if there was a bullying nurse in there somewhere. That increases the risk for med errors. Reported to administration, but not dealt with appropriately, so the bullying continues for years. So does a policy of “blame the nurse” when Pharmacy is confronted with sending up the wrong medication in a very similar package AND there have been problems with the Pyxis machine not scanning the meds correctly AND it’s crazy busy. I’m the unfortunate nurse who worked under these circumstances and luckily only made minor med errors that did not harm the patient. In fact, they were more helpful to the patient!

    • teresa January 7, 2017 at 8:52 pm - Reply

      I do not see anywhere in the story that a “bully nurse” was indicated

  2. Elizabeth Hopkins January 7, 2017 at 1:32 pm - Reply

    Two years ago I was sent home from an Emergency Room without tests or treatment for severe abdominal pain. Around 30 hours later my sigmoid colon ruptured in four places. Another four days later I had surgery (without proper informed consent – was lead to believe they were going to drain abscesses and allow my bowel to heal on its own) and wound up an ostomy bag and my instestines badly scarred and glued together. Three weeks ago I had Hartman’s Reversal. I don’t believe in surgery and now I’ve had two – no more ostomy bag, but I’m still suffering horrifically. I guess there is so much that can go wrong, that could have been prevented. I am disabled physically and mentally because of something that probably could have been prevented.

  3. Karen b January 16, 2017 at 5:16 am - Reply

    My wonder is
    1. Why did the nurse “decide” to give the Demerol. If it was changed to prn then the dr should’ve changed the dose. If it was a scheduled order, then luckily it hadn’t been given regularly.
    2. Where is the dr in this. I’m sorry but as an er nurse (9months med surg) I see the blame that gets placed on the nurses. Was the dr called (yet he didn’t pick up, or yelled at the nurses who were trying to clarify). I’ve had times where I put that the pt refused because the dr would yell while I was trying to clarify. One friend was even yelled at for calling a dr during his favorite commercial!!! No joke. I was so sick of being the piñata while drs drive around in their Teslas.

  4. Victoria Arico January 16, 2017 at 1:07 pm - Reply

    I can’t believe in this day of age that this medication error could happen. So many departments dropped the ball on this dermerol order. When a post-op comes up to a med/surg floor all orders are checked in recovery room then the pharmacist checks them, then the UC/unit secretary, then the nurse who receives the patient and all the other shift nurses that follow. Yes the doctor made the first mistake by leaving the demerol order but look how all the check areas dropped that follow . Why are nurses not having a questioning attitude on this order and who orders demerol these days for postop med. I only see it used for postop shivers in recovery room , never on the med/surg floors. Why was he having such severe post op pain day 3-4, that is a flag that this patient needs to be assessed by MD stat, not the correct path for a simple appy in a young person. If the vicodin was so ineffective the Nurse should have called the MD not her nurse manager. So many mistakes just reading this and prior to him coding was he lethargic or vital signs off. It saddens me to read these stories. As a RN for 38 years, I find this hard to believe that this error took place. I also didn’t see anywhere about a bully nurse mentioned?

  5. DDD January 16, 2017 at 3:22 pm - Reply

    I worked as a hospice nurse for over 12 years. One of my patients had not had a bowel movement in 7 days, inspirit of taking all the meds to have one. I called the doctor, got an order and dis-impacted an extremely large amount of stool. The family complained and threatened to sue because ” they did not consent” to the dis-impaction, even thou the patient was able to consent herself at that time, needless to say I got fired. Nurses take the brunt of it all….I bet the doctor didn’t get in trouble, only the nurse.

  6. Deb M. January 26, 2017 at 4:18 pm - Reply

    IV Demerol for pain? A somewhat outdated choice of pain medication in my part of the US. A safer med could have been chosen.

  7. Barbara January 27, 2017 at 7:10 pm - Reply

    I am an accreditation nurse and I can’t tell you how many times I have educated nurses on a ‘complete medication order’ and ‘therapeutic duplication’ and that they must NEVER ‘decide’ which med to give. That is practicing outside of their scope. If they have to ‘decide’ then they do not have a complete medication order. I also can’t tell you how many have argued with me that they should be allowed to decide what is best for the patient. There were a lot of holes in the cheese that lined up for this error to happen and it is not just the Nurse’s error. The responsible persons to me include the physician, the nurse and the hospital.

  8. Roberta Gasper January 28, 2017 at 10:37 pm - Reply

    I have been a nurse for 25 yrs. It was all I ever wanted to do….but it has been a struggle all the way. Started as a CNA and today hold a Master’s and am a Dir of Nursing. It is either a struggle with management or the floor staff who “just don’t care.” I am at the crossroads right now. I want OUT.

  9. Mary E Repp April 26, 2017 at 3:14 pm - Reply

    As a nurse for over 40 years (staff nurse, manager, educator, researcher, board of nursing staff, etc), I found as a patient and as a family member of a patient, that nurses in the local hospital often didn’t know what medications they were giving and rarely knew why they were giving it and how it should be given. As a University professor for years and having investigated nurse practice problems, I find this indefensible. Every nurse should know what they are giving and why – and side effects, etc. They are the patient’s advocate. Clarifying physician orders is a responsibility of every nurse, even if the physician doesn’t like it. Also, the pharmacy should have also questioned the continuation of the IV demerol. The nurse and pharmacy should have questioned the use of demerol, as pain experts do not recommend its use in most situations for pain control (there may be exceptions). The physician, nurses (all nurses caring for patient & nurse manager), and pharmacy all did not act appropriately.

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