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10-Fold Overdose Results in Woman’s Death, Million Dollar Settlement | Daytona Beach Medical Malpractice Attorney

10-Fold Overdose Results in Woman’s Death, Million Dollar Settlement

Medical providers must take every precaution to ensure proper medication treatment and to quickly recognize when an prescription order is 10 times the normal dose.

Indeed, medication reconciliation is an important safety check where the right drug, right dose, right frequency, and right route of administration are verified.

Because such a verification process did not occur, the 83-year-old woman in this case received a 10-fold overdose of digoxin over four days, resulting in acute kidney/renal failure, cardiac arrhythmia, and death from renal failure and cardiomyopathy. Doctors gave her digoxin to treat her congestive heart failure.

Providers in the emergency room believed that the patient would benefit from rehabilitation before returning home, so she was transferred to a rehab facility for medical monitoring and therapy to improve her function. The woman had coronary artery disease and a previous coronary bypass surgery, mitral valve disease with replacement, congestive heart failure, and chronic renal insufficiency

The transfer medication list included “Digoxin 0.625 mg daily.” However, she was actually taking 0.0625mg. Her home medication list had stated “0.0625” for the Digoxin, but did not include the unit, and was not checked during medication reconciliation.

At the rehab facility, the computer entry system did not allow for mg or milligrams, and the admitting resident correctly converted the incorrect digoxin dose from mg to mcg or micrograms, but the order was still incorrect. The order at the rehab facility was for Digoxin 625 mcg, when it should have been 62.

The pharmacist reviewed the woman’s orders, entered the digoxin dose into the computer system, and received a warning indicating the amount exceeded the maximum daily dose.

The pharmacist overrode the computerized system alert, and failed to contact the ordering doctor to verify the dosage, which is hospital policy for when a discrepancy occurs.

The registered nurse transcribed 625 mcg daily to the medication administration record and documented that medications were administered. Thus, the patient was given 10 times the intended dose of digoxin for four days.

She complained of nausea, and was treated with compazine and zofran. Her heart rate had dropped into the 30’s, and her blood work revealed an elevated potassium level (7). Further testing showed a digoxin level of 27.5 (normal therapeutic range: 0.8 to 2 ng/ml). She was transferred to a tertiary facility for treatment, where she returned to baseline.

After the incident occurred, the rehab admitting nurse denied that the patient received Digoxin, stating she had neglected to circle it on the form to reflect that it was not given. The nurse amended the medical record to indicate she did not provide the digoxin, and then she dated the note as though she had written all of it that day.

Six weeks later, the patient died from renal failure and cardiomyopathy.

The patient’s family sued the rehab facility resident, pharmacist, and admitting nurse, claiming the patient suffered a preventable and premature death as a result of complications of a multi-day overdose of digoxin. The case was settled for more than $1 million.

The family had a strong medical malpractice case based on these factors:

Failure by the admitting doctor to recognize the patient’s prescribed dose exceeded the maximum daily dose. The most common types of prescribing or ordering error involve the wrong dose. A clinician’s reliance on prior information can lead to this kind of prescribing error.

The doctor was allowed to enter a high dose of digoxin into the computer entry system. A reliable system with decision support tools should be in place to assist providers and provide warnings when medication doses exceed the maximum daily recommendation. A provider can also have another person double check their calculation when converting a medication from one unit to another to minimize error.

The pharmacist overrode the computerized system alert, and did not consult the physician for verification. Failing to adhere to hospital policies and procedure can lead to patient harm. Computerized alerts are in place for patient safety and should not be easily removed.

Nurses did not recognize the high dose or question the digoxin order. Adverse events can occur when nurses do not have enough information about the medications they are administering. It is important to know the indications, appropriate dosing and potential adverse reactions, in order to help reduce medication errors.

The admitting nurse altered the patient’s medical record after the fact. Improper corrections or additions are unacceptable fraud.

For more on medical safety issues, see the library of articles by Daytona Beach medical malpractice attorney.



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