Question

[The plaintiffs are the parents of an infant who died after a medication error in a hos-pital. She was given an injection of a heart drug that should have been administered orally. The trial court found in the plaintiffs’ favor, and the defendants appealed. Shortly after her birth, the Norton baby was diagnosed as having congenital heart disease and was placed on Lanoxin (a form of digitalis) to strengthen her heart and reduce her pulse rate. She was discharged from the hospital at two-and-a-half months of age, and her mother administered the medication at home by using a medicine dropper. The child was readmitted about two weeks later—on December 29, 1959—by her pediatrician, Dr. Bombet.]On this occasion [Dr. Bombet] issued admission orders on the infant to be placed in the child’s hospital chart or record. Included in his admission orders were instructions regarding medication, diet, etc., and the notation that special medication was being administered by the mother. In this connection it appears that Mrs. Norton pre-ferred to continue administration of the daily maintenance dose of the Lanoxin herself since she had been performing this function since the child’s initial admission to the hos-pital on December 15th. Dr. Bombet noted in the hospital admission orders of December 29, 1959, that special medication was being given by the mother to thusly advise the hos-pital staff and employees that some medica-tion was being administered the child other than that which he placed on the order sheet and would, therefore, be administered by the hospital nursing staff. On January 2, 1960 (Saturday) Dr. Stotler examined the Norton baby at approximately noon while in the course of making his rounds in the hospital. As a result of this examina-tion he concluded that the child needed an increase in the daily maintenance dose of Lanoxin and instructed Mrs. Norton, who was present in the room, to increase the daily dose of the Lanoxin for that day only to 3 c.cs. instead of the usual 2.5 c.cs. Following this instruction to Mrs. Norton, Dr. Stotler went to the nurse’s station in the hospital pediatric unit floor to check the hospital chart or record on the Norton infant and noted on the Doc-tor’s Order Sheet contained therein certain instructions among which only the following is pertinent to the issues involved herein: “Give 3.0 cc Lanoxin today for 1 dose only.” Dr. Stotler’s entry of the foregoing order for medication constitutes the basis of plain-tiff ’s claim against Aetna as the professional liability insurer of Dr. Stotler. It is frankly conceded by Aetna that unless Dr. Stotler indicated on the order sheet that he had instructed the patient’s mother to increase the daily maintenance dose of Lanoxin to 3.0 c.cs. and administer the medication, his entry of the aforesaid prescription on the order sheet would indicate that the nursing staff of the hospital was to give the medication prescribed. It is further conceded that under such circumstances the child was subjected to the possibility of being administered a sec-ond dose of Lanoxin. The possibility thus pre-sented is exactly what occurred in the instant case. A member of the nursing staff noting Dr. Stotler’s orders, administered 3 c.cs. of Lanoxin in its injectible form instead of the elixir form which Dr. Stotler intended. . . . It is readily conceded by all concerned that the 3 c.cs. of Lanoxin administered the baby by hypodermic was a lethal overdose and was in fact the cause of the infant’s demise. . . . [The day in question was a Saturday, and the regular staff was not on duty. Mrs. Flor-ence Evans, an RN whose regular duties were administrative in nature, was assisting in the pediatric unit that day. She had not engaged in the actual clinical practice of nursing for some time, and she did not know that Lan-oxin was available in oral form; the last she knew, Lanoxin was given only by injection. Noting the doctor’s orders for “3 cc of Lan-oxin,” and seeing no indication that it had been given, she decided to inject the medi-cation herself, even though she sensed that this “appeared to be a rather large dose,” according to the court.] . . . She discussed the matter very briefly with the student nurse, Miss Meadows, and inquired of the Registered Nurse, Miss Sipes, whether or not the child had previ-ously received Lanoxin. Mrs. Evans then examined the patient’s hospital chart and found nothing [to indicate that] the child had been receiving Lanoxin while in the hospital. . . . Considering administration of the drug only by hypodermic needle, Mrs. Evans, accompanied by the Student Nurse, Miss Meadows, went to the medicine room of the pediatric unit and obtained two ampules of Lanoxin each containing 2 c.cs. of the drug in its injectible form. While pondering the advisability of . . . administering what she considered to be a large dose, Mrs. Evans noted that Dr. Beskin, one of the consultants on the child’s case, had entered the pediatric ward so Mrs. Evans consulted him about the matter and was advised that if Dr. Stotler prescribed 3 c.cs. he meant 3 c.cs. Still not certain about the matter Mrs. Evans also discussed the subject with Dr. Ruiz and was informed by him in effect that although the dose was the maximum dose that if the doc-tor had prescribed that amount she could give it. [Despite her misgivings, she did give the injection. The baby went into distress, and despite emergency efforts, she died a little more than an hour later.] . . . The rule applicable in the instant case is well stated in the following language [of an earlier Louisiana case]: (1) A physician, surgeon or dentist, according to the juris-prudence of this court and of the Louisiana Courts of Appeal, is not required to exercise the highest degree of skill and care possible. As a general rule it is his duty to exercise the degree of skill ordinarily employed, under similar circumstances, by the members of his profession in good standing in the same com-munity or locality, and to use reasonable care and diligence, alone with his best judgment, in the application of his skill to the case. [I]t is manifest that Dr. Stotler was negli-gent in failing to denote the intended route of administration and failing to indicate that the medication prescribed had already been given or was to be given by the patient’s mother. It is conceded by counsel for Dr. Stotler that the doctor’s oversight in this regard exposed the child to the distinct possibility of being given a double oral dose of the medicine. Although it is by no means certain from the evidence that a second dose of oral Lanoxin would have proven fatal, Dr. Stotler’s own testimony dose [sic] make it clear that in all probability it would have produced nausea. In this regard his testimony is to the effect that even if the strength of two oral doses were sufficient to produce death in all probability death would not result for the reason that nausea pro-duced by overdosing would have most prob-ably induced the child to vomit the second dose thereby saving her life. The contention that Dr. Stotler followed the practice and custom usually engaged in by similar practitioners in the community is clearly refuted and contradicted by the evi-dence of record herein. Of the four medical Chapter 7: Liability of the Healthcare Institution231experts who testified herein only Dr. Stotler testified in effect that it was the customary and usual practice to write a prescription in the manner shown. The testimony of Drs. Beskin, Bombet and Ruiz falls far short of corroborating Dr. Stotler in this important aspect. The testimony of Dr. Stotler’s col-leagues was clearly to the effect that the bet-ter practice is to specify the route of adminis-tration intended. . . . In view of the foregoing, we hold that the act acknowledged by Dr. Stotler does not relieve him from liability to plaintiffs herein on the ground that it accorded with that degree of skill and care employed, under similar circumstances, by other members of his profession in good standing in the community. We find and hold that the record before us fails to establish that physicians in good standing in the com-munity follow the procedure adopted by defendant herein but rather the contrary is shown. Pretermitting the issue of charitable immunity (with which we are not herein concerned in view of the fact that the suit is against the insurer of the hospital in the instant case) it is the settled jurisprudence of this state that a hospital is responsible for the negligence of its employees including, inter alia, nurses and attendants under the doctrine of respondeat superior. [I]t is not disputed that Mrs. Evans was not only an employee of the hospital but that on the day in question she was in charge of the entire institution as the senior employee on duty at the time. Although there have been instances in our jurisprudence wherein the alleged negli-gence of nurses has been made the basis of an action for damages for personal injuries . . . we are not aware of any prior decision which fixes the responsibility or duty of care owed by nurses to patients under their care or treatment. The general rule, however, seems to be to extend to nurses the same rules which govern the duty and liability of physicians in the performance of profes-sional services. Thus . . . we find the rule stated as follows: * * * The same rules that govern the duty and liability of physicians and surgeons in the performance of professional services are applicable to practitioners of the kindred branches of the healing profession, such as dentists, and, likewise, are applicable to practitioners such as drugless healers, ocu-lists, and manipulators of X-ray machines and other machines or devices. The foregoing rule appears to be well-founded and we see no valid reason why it should not be adopted as the law of this state. Tested in the light of [this rule] the negligence of Mrs. Evans is patent upon the face of the record. We readily agree with the statement of Dr. Ruiz that a nurse who is unfamiliar with the fact that the drug in question is prepared in oral form for admin-istration to infants by mouth is not properly and adequately trained for duty in a pediat-ric ward. As laudable as her intentions are conceded to have been on the occasion in question, her unfamiliarity with the drug was a contributing factor in the child’s death. In this regard we are of the opinion that she was negligent in attempting to administer a drug with which she was not familiar. While we concede that a nurse does not have the same degree of knowledge regarding drugs as is possessed by members of the medical profession, nevertheless, common sense dic-tates that no nurse should attempt to admin-ister a drug under the circumstances shown in [this] case. Not only was Mrs. Evans unfa-miliar with the medicine in question but she also violated what has been shown to be the rule generally practiced by the members of the nursing profession in the community and which rule, we might add, strikes us as being most reasonable and prudent, namely, the practice of calling the prescribing physician when in doubt about an order for medica-tion . . . For obvious reasons we believe it the duty of a nurse when in doubt about an order for medication to make absolutely certain what the doctor intended both as to dosage and route. . . .. . . The evidence . . . leaves not the slightest doubt that when Dr. Stotler entered the order for the medication on the chart, it was the duty of the hospital nursing staff to adminis-ter it. Dr. Stotler frankly concedes this impor-tant fact and for that reason acknowledged that he should have indicated on the chart that the medication had been given or was to be given by the mother, otherwise some nurse on the pediatric unit would give it as was required of the hospital staff. Not only was there a duty on the part of Dr. Stotler to make this clear so as to prevent duplication of the medication but also he was under the obligation of specifying or in some manner indicating the route considering the drug is prepared in two forms in which dosage is measured in cubic centimeters. In dealing with modern drugs, especially of the type with which we are herein concerned, it is the duty of the prescribing physician who knows that the prescribed medication will be administered by a nurse or third party, to make certain as to the lines of communica-tion between himself and the party whom he knows will ultimately execute his orders. Any failure in such communication which may prove fatal or injurious to the patient must be charged to the prescribing physician who has full knowledge of the drug and its effects upon the human system. The duty of com-munication between physician and nurse is more important when we consider that the nurse who administers the medication is not held to the same degree of knowledge with respect thereto as the prescribing physician. It, therefore, becomes the duty of the physi-cian to make his intentions clear and unmis-takable. If, as the record shows, Dr. Stotler had ordered elixir Lanoxin, or specified the route to be oral, it would have clearly informed all nurses of his intention to admin-ister the medication by mouth. Instead, however, he wrote his order in an uncertain, confusing manner considering that the drug in question comes in oral and injectible form and that in both forms dosage is prescribed in terms of cubic centimeters. It is settled jurisprudence of this state that where the negligence of two persons combines to produce injury to a third, the parties at fault are [jointly] liable to the injured plaintiff. [Thus, the court affirms the jury’s verdict and holds everybody liable.]

1. How many mistakes can you count in this set of facts? At how many points could the chain of errors have been interrupted?

2. If you were the hospital administrator, the chief of the medical staff, or the chief of nursing, what action would you take to prevent recurrence of this tragedy?

3. This child’s death occurred more than 50 years ago, yet a 2007 report by the Institute of Medicine (Preventing Medication Errors) states that at least 1.5 million people are injured each year because of medication errors. According to the report, on average at least one medication error is made per hospital per patient per day. What safeguards are in place in hospitals today to prevent these kinds of mistakes?

Answer 1

1. How many mistakes can you count in this set of facts? At how many points could the chain of errors have been interrupted?

The number of mistakes can be identified in the set of facts chain of errors have been interrupted which are enlisted below=

• During the medication dispensation, no interruption was made by the pharmacist anywhere in the entire chain which could result in the interruption in case of possible medication mistakes.
• No directives \were provided by Dr. Stotler about the manner in which the medication had to be administrated. If the chart contained adequate information, it would have been possible to avoid the incident.
• The chart was lacking any section which can indicate that the right patient is given the required medication. It can be seen as a fatal error and It could have prevented the double dosing.
• The nurse was not aware fully about the manner of administration. No consultation was made with the doctor by Mrs. Evans before administrating the medicine. It could have been avoided by proper consultation with the doctor.
• The mother should not be permitted to give the medicine to the patient within the premise of the hospital as the safety of the patient within the premise of the hospital is the responsibility of the hospital.

2. If you were the hospital administrator, the chief of the medical staff, or the chief of nursing, what action would you take to prevent recurrence of this tragedy?

In this case, I would develop a set of protocols which must be followed strictly every day and this could include following=

• All the activities of the staff members would be monitored and ensure that they are well qualified to execute their duties.
• I would make sure the adherence of all the SPOs.
• Proper information about the medication would be provided to the patient.
• The pharmacy should be involved in the administration of the medication.
• Computerized Physician Order Entry (CPOE) can be implemented to control medication mistakes.
• Bar codes scanners and computerized patient information systems can be used to provide the medication history of the patient.

3. This child’s death occurred more than 50 years ago, yet a 2007 report by the Institute of Medicine (Preventing Medication Errors) states that at least 1.5 million people are injured each year because of medication errors. According to the report, on average at least one medication error is made per hospital per patient per day. What safeguards are in place in hospitals today to prevent these kinds of mistakes?

Almost every hospital takes a number of steps to avoid any medication mistakes. However, these methods could vary. At present, the different safeguards to prevent any mistakes are given below=

• There should be a committee which must have the members from pharmacists, physicians, nurses, and other health professional and they should form the policies related to the evaluation and selection of drugs in the hospital
• Due care and a lot of monitoring must be ensured while selecting the employees who will take care of the medication ordering, preparation, dispensing, and administration
• All the policies and procedures must be communicated to the staff members about the medication.
• The safe environment has to be developed for the preparation and dispensation of the medication.
• In order to avoid any drug medication errors, there must be a provision of formal Drug Use Evaluation programs
• Only pharmacists will be authorized for medication.
• All healthcare providers and patients must be having suitable drug information
• The prescribed medication by the doctors must be sent to the pharmacy and any mistake that can be identified by the pharmacist.
• For the safe administration of medications, there are some double-checking sheets used by the hospitals.

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