Nurse Malpractice Case Study with Risk Management Strategies : Administering Improper , Excessive Medication Dose
By Lynn Pierce and Georgia Reiner
Medical malpractice claims may be asserted against any healthcare practitioner , including registered nurses ( RNs ). This nursing malpractice case study involves an RN working for a home healthcare agency . The RN was caring for a 19-year-old female patient who was essentially unresponsive due to multiple sites of malignant neoplasms in her brain . These sites were initially diagnosed when she was 15 years old and resulted in multiple surgeries and chemotherapeutic treatments .
The patient was neurologically devastated . She was non-communicative , had a tracheotomy , and was ventilator dependent . The patient ’ s extensive medical history included diabetes mellitus type I , epilepsy / seizures , kidney disease , bowel / bladder incontinence , cortical blindness , dysphagia , contractures , convulsions , central sleep apnea , paralysis of vocal cords and larynx , obstructive hydrocephalus , hypothyroidism , panhypopituitarism , and adrenal disorder .
Recently , the patient was admitted to the hospital after experiencing atrial flutter and cardiac arrest at home but recovered and had mostly returned to baseline . During her hospital admission , she was placed on nadolol ( a beta blocker ) 30 mg twice a day ( BID ) and flecainide ( an anti-arrhythmic ) 25 mg ( 1.3 mL ) twice a day via gastrostomy tube ( G-tube ). At discharge , the hospitalist recommended that she wear a transtelephonic Holter monitor to evaluate any additional arrhythmias .
Discharge to Home Upon discharge from the hospital , the patient was admitted to a home healthcare agency for 24-hour continuous home nursing care . During the home healthcare admission , the patient ’ s mother changed the patient ’ s code status from a Do Not Resuscitate ( DNR ) to a Full Code .
The mother ’ s rationale for updating the patient ’ s code status was her belief that her daughter was now medically stable and had been cancer-free for almost a year . The code status was changed despite the mother being told that during the previous hospital admission the patient ’ s life expectancy would be less than six months . The home healthcare agency ’ s admission assessment , completed by the clinical supervisor , noted the patient ’ s rehabilitation potential to be “ poor ” and that her overall prognosis was “ poor ” as well .
The RN reported to the patient ’ s home the morning following the patient ’ s admission to home healthcare . The RN had cared for the patient previously and was familiar with her medications and daily routines . Prior to starting his shift , the night nurse gave him a report on the patient ’ s current status and the updated plan of care , including the new medications .
The RN correctly noted the new medication orders for nadolol 10 mg BID and flecainide 25 mg ( 1.3 mL ) BID via G-tube . At 8:00 a . m ., the RN administered routine medications to the patient and performed her morning care . Between 9:45 a . m . and 11:45 a . m ., the RN continued to provide routine patient care . At 12:00 p . m ., the RN administered flecainide and nadolol , as well as other routine medications . However , instead of administering 25 mg ( 1.3 mL ) of flecainide as prescribed , he administered 25 mL , which was approximately 19 times the prescribed dosage .
At approximately 2:00 p . m ., the RN identified changes in the patient ’ s heart rate and vital signs . He noted that the patient was bradycardic with a weak pulse and unable to be aroused . The RN called the patient ’ s mother at work to report the changes in the patient ’ s condition . The mother advised him to call the patient ’ s cardiologist about the change . The RN contacted the cardiologist and was advised to call 911 for an ambulance to take the patient to the emergency department ( ED ).
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