This month we look at a case where a nurse practitioner (NP) was sued after a patient was harmed due to a prescribing error. How could this have been avoided?
The patient, Ms. E, was in her 60s and suffered from various chronic conditions, including end-stage renal disease, congestive heart failure, and obstructive sleep apnea. She developed a rash on her neck. Her regular primary care physician, whom she saw regularly for treatment of her chronic problems, was on vacation, so she went to her local clinic for treatment.
At the clinic, she was seen by Ms N, a NP who examined the rash and diagnosed it as shingles. The patient was prescribed valaciclovir at the normal dosage for the treatment of herpes zoster (1000 mg three times a day). In prescribing the drug, Ms. N did not take into account the patient’s kidney disease, which should have signaled the need for a lower valacyclovir dosage.
Mrs E filled out the prescription and started taking the drug. Within days of starting the medicine, she started experiencing tremors and spastic movements in her arms and legs. She called her primary care physician’s office and described her symptoms to a personal assistant who advised her to go to the hospital. At the hospital, Ms. E was diagnosed with a valacyclovir overdose and was admitted to the hospital.
Over the next 3 days, Ms. E underwent dialysis to clear the drug from her system. After the dialysis treatments, the tremors and jerky movements resolved. At the same time, the patient began to have difficulty breathing and her vital signs became unstable. Ms E was intubated and placed on a ventilator in the intensive care unit (ICU), where she developed pneumonia.
When she got better, she was taken off the ventilator and transferred to a rehabilitation area of the hospital, however, she didn’t fare well. She required dialysis and became weak and hypotensive. She was transferred back to the ICU where her respiratory status worsened and she again required intubation and mechanical ventilation. Her situation continued to deteriorate due to her compromised condition. She developed a blood clot in her leg which required surgery to insert a filter to stop the clot from reaching her lungs. She required a tracheostomy and a feeding tube.
The patient was transferred to a long-term care facility where they attempted, unsuccessfully, to wean her from mechanical ventilation. Within a month, Ms E was found unconscious in her room and was rushed to hospital where she died.
Ms. Es, a widow, sought the opinion of a lawyer for the plaintiff. The attorney consulted with an experienced physician to discuss whether the prescribed dose of valaciclovir was below standard of care and whether it was the proximate cause of the patient’s death. The doctor was critical of Ms. Ns’ prescription and believed that this caused Ms. Es’ death.
The plaintiff’s attorney then consulted with another medical expert to assess whether the hospital had provided adequate treatment and care to the patient. The expert believed that the hospital had met the standard of care in treating the patient.
The attorney suggested approaching NP’s employer to explore a possible negotiated settlement. At the meeting, defense attorneys argued that even though the NP had overprescribed valacyclovir, the overdose only caused temporary damage. They held that the NP was only liable, if at all, for a few days of damage, but not for the lengthy hospitalization or death. The parties failed to settle, and the plaintiff’s attorney officially filed the lawsuit.
Discovery began and included the swapping of thousands of pages of medical records. Depositions from all parties and witnesses have been completed. Expert reports were exchanged. The defense was eventually forced to admit that Ms. N should have prescribed a much lower dose of the drug, however, she denied that this error caused the patient any serious injury or death. After several dialysis sessions, the drug was cleared from the patient’s system, the defense argued; thus, the error only caused the temporary shaking and spastic movements. The patient’s death, the defense argued, was caused by her extensive pre-existing comorbidities, which would have prevented her from living long even if she had received the right dose of valaciclovir.
The plaintiffs were quick to argue that the drug overdose was the trigger that set in motion the unfortunate cascade of events that ultimately led to the patient’s death.
After the court set a trial date, settlement negotiations resumed, this time with the assistance of a private mediator. In mediation, just weeks before the trial began, the parties reached a confidential agreement to resolve the case.
It is not uncommon for cases to be settled out of court before trial. In fact, most cases are resolved or filed and never come to trial, and for good reason. Trials are extremely expensive and the outcome is never predictable. In many cases, settlement is a far better outcome for all involved.
Ms N could have avoided the case altogether if she had taken the patient’s medical history into account when deciding what and how much to prescribe. Even if a patient is seeking help for something that seems minor—a rash, cut, sprain—it is essential to understand the patient’s medical history before prescribing medications.
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