Nurse Convicted in Medication Error Case

While health care professionals do not commonly face criminal charges for cases of negligence, the following cases show the possibility exists. For example, a nurse in Tennessee was recently convicted of gross neglect of an impaired adult and negligent homicide as a result of a medication error.  The nurse intended to withdraw Versed® from a medication cabinet on the floor, but retrieved vecuronium instead.  Criminal charges were filed after the patient died.  This case is similar to the case of the pharmacist in Ohio in 2006.  In that case, an 18 month old patient mistakenly received her chemotherapy treatment in a bag of concentrated sodium chloride instead of normal saline.  After the patient’s death, the pharmacist faced criminal charges, was convicted, and served more than a year in prison.


In both of these cases, there were systemic issues that contributed to the error. It appears staff and management tolerated situations that contributed to these mistakes.  Among these were supply issues, workloads, computer downtime, machine/technology reliability, and policy decisions that did not make patient safety the first priority.


A culture of patient safety must be created and maintained in the pharmacy and other health care facilities.  This culture does not just magically happen.  It takes everyone to make this happen.  Any systemic or personnel issue must be identified, brought to management’s attention, and corrected.  Regardless of the issues, the health care professionals involved in these cases received most of the blame and all of the punishment.


To protect yourself, look critically at the working conditions and procedures in your practice setting.  Are there issues that increase the chance of patient injury?  If so, bring them to management’s attention immediately.  If ownership and/or management ignores requests for change, it may be only a matter of time before a serious incident occurs.  Pharmacy Professional liability insurance is intended to provide coverage for civil cases, such as negligence.  These policies do not provide coverage for criminal proceedings.  However, policies issued by Pharmacists Mutual do provide a limited reimbursement for legal fees in some criminal situations.  Rather than relying on this limited reimbursement, your best strategy is to rectify issues before a patient is injured or dies.