Medication Error Lawsuit Settles for $1.75M
2015 Medical Malpractice Trial Report
Death from blood clot after withholding of anticoagulation medicine (Heparin) due to medication mix up
The plaintiff’s decedent died on 9/24/09 at age 54 from a pulmonary embolism (blood clot).
The patient’s medical history included hypertension, obesity, adult onset diabetes, hyperlipidemia, venous stasis ulcers and pulmonary embolism. In addition, the patient had been diagnosed with esophageal cancer and was undergoing chemo and radiation therapy.
On 9/17/09, the patient presented to the hospital with dysphagia, nausea, vomiting and abdominal pain. He was admitted to the hospital for PICC line placement for TPN, treatment of dehydration and nutritional and oncology consult.
On 9/24/09 the patient was pronounced dead following an acute episode of chest pain and respiratory arrest. Autopsy findings revealed the presence of a large saddle pulmonary embolism.
An investigation found that the patient’s death was associated with a medication error. According to the investigation, the patient refused heparin pre-operatively (all 3 doses for 3 days) on 9/18/09, 9/19/09 and 9/20/09. The handwritten nursing progress notes for each of said dates do not reference that the patient refused any medication. Rather, there are entries in nursing notes for the 19th and 20th to “give all medications as ordered.”
According to the computer generated medication administration records, on 9/18/09 nurses electronically noted that the patient refused the 1:00 p.m. and 9:00 p.m. prescribed heparin dosages, on 9/19/09 the patient refused the 5:00 a.m. prescribed dosage of Heparin, and the patient was not given his 1:00 p.m. dosage of Heparin because he was “ambulating.” Also, the 9:00 p.m. dosage for 9/19/09 was refused, and on 9/20/09 the 5:00 a.m. Heparin was “refused” and the 1:00 p.m. dosage was not given because the patient was “ambulating.”
The next four doses of heparin (three doses for 9/21/09 and the morning dose for 9/22/09) were then reportedly held by the nursing staff in anticipation of surgery without a physician order. According to the investigation, the patient’s physicians were not informed until after his death that the patient had not received the prescribed heparin from 9/18/09 to 9/22/09.
The plaintiff claimed the nurses failed to timely inform the attending physicians of the medication refusal so that measures could be taken to insure anticoagulation. Instead, the doctors were led to believe that all medications were given. The plaintiff claimed the failure to provide anticoagulation led to a fatal blood clot.
The defendants contended that the patient refused the medication, and it was not incumbent on the staff to overrule the patient’s wishes. The defendant’s also contended the life expectancy was limited given the esophageal cancer.
This medical malpractice case settled shortly before trial for $1,750,000.
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