Dr. ordered 30 mgs Dilaudid: RN questioned order resulting in change.

CASE ON POINT: Wall v. Hillside Hosp., 2008 TNCIV M2005-02529-COA-R-3 (01/31/2008)--TN

ISSUE: Nurses have a responsibility not to follow doctors' orders when they know that the medication or dosage may be detrimental to and/or fatal to a patient. In this Tennessee case after a physician mistakenly ordered 300 mgs of Dilauded for a patient, a nurse, well aware that the usual dosage is 3 rags contacted the doctor to confirm that he wanted 300 mgs (a fatal dose) given to the patient. Fortunately, at least according to the nurse, the physician's error was caught by the nurse who only administered 3 rags of Dilauded. However, once the patient and her family became aware of the physician's error they proceeded on the theory that the 30 mgs dosage was, in tact, administered to the patient.

CASE FACTS: Carla Wall was admitted to Hillside Hospital on December 27, 2003, with a diagnosis of acute multiple sclerosis exacerbation, optic neuritis of the right eye, and severe eye pain. On December 28, the patient went into respiratory arrest. She was resuscitated and treated. The patient was released form the hospital on January l, 2004. The patient, her husband and family came to realize that her attending physician had made an error and written an order for 30 mgs of Dilaudid. The Walls sued the hospital, the patient's attending physicians, Drs. Akram Haggag and Salah Faour, LPN Donna Watson and RN Jennie Heflin. The Walls alleged that Dr. Haggag mistakenly ordered 30 rags of Dilaudid every four hours. The evidence indicated that on the day of admission, Dr. Haggag ordered 30 rags of Dilaudid every four hours and that the usual dosage is 3 mgs every four hours. However, according to the defendants, Nurse Watson called Dr. Faour to confirm what appeared to be an incorrect dosage before administering it. According to the defendants, after that conversation the dosage was changed to the correct dosage. The defendants contended that the patient never received an incorrect dosage because the error was discovered before the drug was administered. The defendants asserted that the medical records supported the contention that the errant dosage was never administered and noted that if it had, more than likely it would have killed the patient. The Walls were unable to get their expert medical witness to testify on their behalf. It was necessary for them to voluntarily submit to a nonsuit so that they could regroup and file another suit after obtaining a cooperative expert medical witness to testify for them. The court granted the plaintiffs' motion for a voluntary nonsuit. However, the Walls construed it to be "with prejudice," and appealed.

COURT'S OPINION: The Court of Appeals of Tennessee affirmed the judgment of the trial court denying the Walls permission to voluntarily dismiss their suit without prejudice and awarded summary judgment to the defendants. The court held, inter alia, that the Walls failed to submit any evidence whatsoever to refute the defendants' evidence that the patient was only given 3 mgs of Dilaudid rather than the 30 mgs that the plaintiffs alleged. The court agreed with the trial court that there was nothing in the case to litigate. The entire case would either rise or fall on the allegations by the plaintiffs that the defendants were guilty of negligence. The plaintiffs were unable to do so because of their failure to produce an expert medical witness, who, after reviewing all of the medical records could testify that the patient was, in fact, given excessive dosages of Dilaudid, which was the cause of the subsequent illness.

LEGAL COMMENTARY: It is frightening to think that any nurse could be put in the dilemma of having to call a physician to confirm the accuracy of his or her orders for meds, whether it be the type of medication, the frequency of administration, or as in this case, the dosage ordered by the physician. It is crystal clear that the physician, in prescribing medication for his patient made a grievous error. In fact, the error was so grievous that had the prescribed dosage been given the patient very likely might have died. Fortunately for all involved, the nurse who was to administer the medication prescribed recognized that the dosage was so far from the usual dosage of 3 rags that it might have caused the patient's death, called the physician to question the order. Accordingly, at least following the hospital's version of what happened, the error was recognized by the physician and the correct dosage of 3 rags was administered. How often have nurses called physicians to confirm similar orders and, to their utter dismay, are told by irate physicians that if that is what they ordered, that is what was to be given, while at the same time admonishing the well intentioned nurse (how dare he or she question the physician's order). Nurses must not be intimidated by such bullying tactics by physicians. If, in fact, a nurse has a good faith doubt about the type of medication, the frequency of administration as ordered by the physician, or, as in this case, the dosage ordered, he or she must stand his or her ground and not give in to any bullying tactics by any physician, but bring the matter to the attention of her superiors and, if necessary, all the way up the chain of command. Nurses owe that duty to their patients.

Meet the Editor & Publisher: A. David Tammelleo, JD, is a nationally recognized authority on health care law. Practicing law for over 40 years, he concentrates in health care law with the Rhode Island firm of A. David Tammelleo & Associates. He has presented seminars on medical, nursing and hospital law throughout the United States. In addition to his writings as Editor of Medical Law's, Nursing Law's & Hospital Law's Regan Reports, his legal articles have been published in the most prestigious health law journals. A prolific writer, his thousands of articles, as well as his achievements as an attorney and lecturer, have won him recognition in Martindale-Hubbell's Bar Register of Preeminent Lawyers, Marquis Who Who in American Law, Who's Who in America and Who's Who in the World