CARE Case Study: Patient dies from prescribed medication intoxication

Summary

Plaintiff alleged 38-year-old husband and father died as a result of prescription overdose after seeking care from multiple providers who were negligent in the treatment and monitoring of the patient and his condition.

Detailed history

A 38-year-old married Caucasian male, Patient, signed a consent for treatment at Psychiatric Clinic, and was seen by Clinic’s Advance Registered Nurse Practitioner (ARNP). ARNP is considered an independent contractor at Psychiatric Clinic, receiving “general supervision” by CARE Professional Liability Association’s Insured Physician, as per the ARNP Act. Under this act, the ARNP has an MD available in emergencies or if the ARNP needs consultation.

The Patient’s care with ARNP at Psychiatric Clinic started with a diagnosis of Bipolar Disorder and he was prescribed Seroquel (300mg qd) and Xanax (1mg prn), with 3 refills.

NOTE: Unknown to Insured Supervising Physician, ARNP, or anyone else at Psychiatric Clinic, but according to records discovered later, Patient had been treated at an Ortho Institute 3 years earlier for neck and arm pain. When Patient called that Ortho Institute asking for a refill for extra strength Vicodin, Ortho Institute denied his request, as Patient had just filled a prescription for 50 extra strength Vicodin and 50 Percocet. It was noted in Ortho Institute’s record that Patient was “taking too much medication.”

Over the next yearPatient returned to Psychiatric Clinic and medications were adjusted slightly to Seroquel (400mg qd) and Xanax (1mg qid), with 3 refills.

Eleven days after the 13-month appointment, Patient returned to Psychiatric Clinic and reported his wife and children left him, and that he had been inconsistent with taking his medication. Patient was prescribed Seroquel (400mg qd) and Xanax (1mg x5), with 2 refills.

Sixteen days after that, Patient returned to Psychiatric Clinic and reported he was doing better and his wife and children had returned. APRN discussed alternatives to Seroquel, but Patient was reluctant. Patient also reported attending AA meetings.

Over the next year, Patient returned to Psychiatric Clinic for ongoing treatment. At a visit two years into treatment, Patient reported losing his health insurance. At the visit 5 months later, Patient reported that he lost his job three months ago and is experiencing increased stress.

One month later, 24 months after beginning treatment at Psychiatric Clinic,Patient was involved in a motor vehicle accident that resulted in disc herniation in his cervical and lumbar spine. Patient sought treatment with a Different MD at Spine Center, as well as with 3rd Provider at Another Clinic. Patient was prescribed Oxycodone (5mg, every 8 hours) from Spine MD, and ibuprofen (800mg, every 8 hours) by the 3rd Provider, Another Clinic’s ARNP, for pain.

Approximately a month after that,Patient returned to the Psychiatric Clinic for the last time, and reported he was still looking for work, and his wife was unemployed as well. There was no indication in APRN’s clinical note that the Patient reported being in a motor vehicle accident or that he was now taking Oxycodone for neck and back pain.

According to testimonies,Spine MD stated in his deposition that he treated Patient for neck and back pain after the motor vehicle accident and he prescribed Patient 5mg of Percocet for pain. He stated that he was aware Patient was prescribed Xanax, but he did not ask the dosage. He stated that he was not concerned with the interaction between Percocet and Xanax, and prescribed a low dose of Percocet. Three months later, Spine MD increased the Percocet to 7.5mg every 8 hours and recommended that Patient obtain a second opinion for possible surgery.

3rd Provider, ARNP, who was also treating the patient for pain post motor vehicle accident, prescribed him ibuprofen 800mg every 8 hours. She reported remembering that Patient was fidgety, anxious, and moving around a lot. Patient also immediately told her that he was allergic to Tramadol, which she interpreted as him seeking a strong pain medication. She stated that she believed Patient exhibited signs of having a drug problem, but acknowledged that she did not document this, nor did she inform anyone of her suspicions. His presenting complaints were headaches, and neck and back pain as a result of the motor vehicle accident. She noticed everything to be going well until the patient realized that he could not get Percocet, oxycodone, or Xanax from her. Patient did report that he had received 15 Percocet pills from the hospital three days prior, but was out or almost out.

Another treating physician, 4th Provider MD, saw the patient one time a month after the motor vehicle accident. Her prescriptions at this time were oxycodone, Seroquel, Xanax, and ibuprofen. She noted that his pulse was high, he had a slight slur in his speech, and he reported that his sleep was affected by position changes. She added that she did not believe he was overmedicated, rather he was adjusting to his medications. Patient reported that he had been taking the Seroquel on a prn basis, and she advised Patient to take all his medications as prescribed. 4th Provider MD reported receiving a phone call, presumably from 3rd Provider APRN, stating that Patient had been seen there and was asking for pain medication but was given ibuprofen and referred to pain management instead.

Meanwhile, Patient’s wife reported making several attempts to get in contact with Psychiatric Clinic’s APRN in which she told the receptionist Patient was “acting crazy”. Each time she called, Patient’s wife was only able to speak with the receptionist, and reported feeling like the receptionist did not care, nor did she ever receive a call back.

Two months later, a member of Patient’s family discovered Patient’s deceased body, and reported that there were pills at his bedside. The medical examiner recorded the cause of death as intoxication by Xanax and Oxycodone in the course of treatment for degenerative joint disease of the cervical spine.

It was noted in the medical record that days before his death, Patient called APRN’s office, with his wife listening in on the call, and asked if his wife could attend his next appointment, to which APRN agreed, although the patient died prior to this appointment occurring.

Plaintiff Allegations

The plaintiff claims that CARE’s Insured MD was negligent due to the following:

  • Failure to perform adequate clinical evaluations,
  • Failure to adequately monitor Patient during the care and treatment of his clinical conditions including his apparent psychiatric disorders,
  • Failure to provide patient instructions to Patient regarding the care and treatment of his apparent psychiatric disorders, and
  • Providing an additional prescription for alprazolam to Patient before the completion of his prior prescription.
  • Plaintiff further alleges that Insured MD and his practice are responsible for the negligence of Psychiatric Clinic’s ARNP, as her supervising physician.
  • Plaintiff alleges that as a result of the negligent acts of the Defendants, Patient died of intoxication of Oxycodone and Alprazolam.

The plaintiff also claims that 3rd Provider is vicariously liable for:

  • Their employed APRN’s as well as the 4th Provider MD’s failure to warn Patient of the hazards associated with prescribing ibuprofen with his other medications and
  • Failing to warn Patient of the dangers of his medication regimen.

Plaintiff claims Spine Clinic is vicariously liable for Spine MD who was negligent when he failed to monitor Patient’s prescription medications.

The Case for Case Studies

As a medical provider, you know the inherent risk and likelihood of unforeseen adverse events. You may need advice when these situations unfold. CARE, through our partnership with OmniSure, offers a helpline specifically for such issues. The helpline assists with questions about specific incidents, risk mitigation, and regulatory-related issues.

We then use the information gathered from our helpline to develop case studies, which in turn help our clients navigate the waters of incident reporting and risk mitigation. The aggregation of this data, coupled with our extensive experience, provides clients with examples, solutions, and best practices of clients that have been in similar situations.  

In this and future posts, we will explore case studies, and how learning from them helps our clients prevent future claims. As an example, this case study outlines a lawsuit wherein the plaintiff alleges that her husband died as a result of a prescription overdose after seeking care from multiple providers – including independent physicians, supervised nurse practitioners, independent advanced practice providers, and specialty clinics – who were negligent in the treatment and monitoring of the patient and his condition. While this case has not been settled yet, it does remind providers of the importance of completing a thorough patient history, as well as patient follow up.

We all make mistakes, in both our personal and professional capacities. To err is human. If you have patient safety or risk management questions, or need guidance after a potentially litigious event, get the guidance of a clinical risk specialist. Don’t go it alone. As a CARE policyholder, you have access to confidential advice-on-demand from a third-party firm that specializes in helping avoid litigation by protecting your patients, your license, and your reputation. Click here for more information.