Introduction

This issue of the UPvision Consulting Insights Newsletter explores the topic of Medication Administration Errors: From Bedside to Courtroom. Medication errors remain a significant concern in healthcare, with implications that span clinical outcomes and legal accountability. This newsletter examines current standards of care, recent scholarly findings, and the implications for medical-legal case work.

Standards of Care and Evidence

Recent literature emphasizes the critical nature of medication administration in patient outcomes. Medication errors can occur during prescribing, transcribing, dispensing, and administration. Nurses, being at the frontline of care, play a pivotal role in preventing these errors.

Studies have identified barriers to error reporting, such as fear of punitive action, unclear definitions of errors, and inadequate knowledge. Standardizing procedures, improving labeling, and fostering a blame-free culture are essential strategies to mitigate errors.

Legal and Case Implications

Medication administration errors often lead to legal scrutiny regarding foreseeability, causation, and damages. Attorneys rely on expert nurse consultants to clarify standards, evaluate documentation, and identify gaps in care.

In litigation, the breach of standard care and its direct link to patient harm are central arguments. Documentation, adherence to protocols, and timely interventions are critical factors in determining liability.

Case Study

Case Study: Fatal Medication Error in the Emergency Department

Mr. J., a 58-year-old male, arrived at the emergency department (ED) with sudden onset of severe abdominal pain, rated 9/10. He was pale, diaphoretic, and hypertensive, with a history of hypertension and type 2 diabetes. The triage nurse quickly assessed him and notified the attending physician, who provided a verbal order for intravenous hydromorphone to relieve his pain.

The order was relayed to a staff nurse, who hurriedly documented it in the electronic medical record. In the process of transcription, the nurse mistakenly entered 10 mg IV hydromorphone instead of the intended 1 mg. The ED was busy, and under pressure to keep patient flow moving, the nurse proceeded without conducting the recommended read-back verification of the verbal order.

The pharmacy received the order electronically. Despite the dose being unusually high for an opioid-naïve patient (has not received the medication before), no alert was triggered in the system. The pharmacist, managing a backlog of orders, approved and dispensed the medication without questioning the dosage.

The bedside nurse retrieved the medication and administered the full 10 mg IV push. Within minutes, the patient became somnolent and then unresponsive. A rapid response was initiated, and the team administered naloxone, but resuscitative efforts failed. The patient suffered respiratory arrest leading to cardiac arrest, and he was pronounced dead shortly thereafter.

Investigation Findings

The hospital’s root cause analysis identified multiple, preventable failures:

• Transcription Error: The nurse documented an incorrect, lethal dose during the initial order entry.

• Verification Failure: The absence of a read-back for the verbal order violated hospital policy and Joint Commission standards.

• Pharmacy Oversight: The pharmacist failed to recognize or challenge the unusually high dose.

• System Gaps: The electronic prescribing system lacked a hard stop or alert for potentially dangerous opioid doses.

• Protocol Breach: The nurse did not question the appropriateness of administering such a high dose to a patient with no documented history of opioid use.

Legal and Financial Outcome

The patient’s family pursued a wrongful death and medical negligence lawsuit. Expert testimony emphasized that a reasonably prudent nurse would have verified the order, and a reasonably prudent pharmacist would have flagged the lethal dose. The hospital elected to settle the case for a large multi-million dollar sum rather than face trial, citing clear system failures and deviations from accepted standards of care.

Lessons Learned:

1. The critical importance of accurate communication

2. The need to enforce double verification of high-risk medications, and adherence to safety protocols.

3. The impact of multiple small errors across different team members on the cause of catastrophic outcomes.

4. The importance of nursing education in relation to the prevention of catastrophic errors.

Quality Improvement Takeaways

Healthcare leaders can reduce liability and improve patient outcomes by implementing the following strategies:

1. Review communication and reporting processes

2. Conduct regular audits of medication administration practices.

3. Provide ongoing education and simulation training for staff.

4. Educate on the appropriate way to comply with implemented double-check systems for high-risk medications and enforce the practice.

5. Foster a culture of safety and encourage error reporting without fear of retribution.

Strategies for Attorneys and Healthcare Professionals

For Attorneys:

1. Engage expert nurse consultants from the start of a case to review documentation and protocols. Legal nurses can perform reviews, but they can also help determine merit, create timeline reports for administration of medications, and examine audit trails for compliance with the rights of medication administration.

2. Focus on deviations from standard care and their impact on patient outcomes. In this case, there were several deviations found that led to the patient’s death.

3. Request policies and procedures for medication administration processes and for safety protocols.

4. Request an appropriate audit trail of the medical record but also of the automated medication cabinet that was accessed for medication.

For Healthcare Professionals and Organizations:

1. Standardize and enforce medication administration protocols.

2. Use electronic health records and automated dispensing systems to reduce human error.

3. Benchmark performance using medication error rates and patient safety indicators.

4. Engage your team or staff in medication administration quality reviews. This will provide an opportunity to improve failing processes but also to enhance your teams performance.

Resources and Next Steps

UPvision Consulting, LLC partners with law firms and healthcare agencies to bridge the gap between nursing practice and legal standards. Contact us for expert nurse consulting services https://upvisionconsulting.com/contact-us

Join us at the Attorney’s Resource Conference for sessions on nursing standards of care, expert testimony, and litigation strategies. Register today https://attorneysconference.com/

References

Afaya, A., Konlan, K. D., & Kim, H. (2021). Improving patient safety through identifying barriers to reporting medication administration errors among nurses: An integrative review. BMC Health Services Research, 21, 1156. https://doi.org/10.1186/s12913-021-07187-5

Yoon, S., & Sohng, K. (2021). Factors causing medication errors in an electronic reporting system. Nursing Open, 8(6). https://doi.org/10.1002/nop2.1038

Koyama, A. K., Maddox, C. S. S., Li, L., Bucknall, T., & Westbrook, J. I. (2020). Effectiveness of double checking to reduce medication administration errors: A systematic review. BMJ Quality & Safety, 29(7), 595–603. https://doi.org/10.1136/bmjqs-2019-010947

Kerari, A., & Innab, A. (2021). The influence of nurses’ characteristics on medication administration errors: An integrative review. SAGE Open Nursing, 7, 1–17. https://doi.org/10.1177/23779608211025802

Coelho, F., Furtado, L., Mendonça, N., Soares, H., Duarte, H., Costeira, C., Santos, C., & Sousa, J. P. (2024). Predisposing factors to medication errors by nurses and prevention strategies: A scoping review of recent literature. Nursing Reports, 14(3), 1553–1569. https://doi.org/10.3390/nursrep14030117