The insured registered nurse (RN) was working for a home healthcare agency. The RN was caring for a 19-year-old female patient who was essentially unresponsive due to malignant neoplasm of multiple sites of her brain. These sites were initially diagnosed when she was 15 years old and resulted in multiple surgical and chemotherapeutic treatments. The patient was neurologically devastated, non-communicative, had a tracheotomy, and was ventilator dependent. The patient's prior medical history was extensive and included diabetes mellitus type I, epilepsy/seizures, kidney disease, bowel/bladder incontinence, cortical blindness, dysphagia, contractures, convulsions, central sleep apnea, paralysis of vocal cords and larynx, obstructive hydrocephalus, hypothyroidism, panhypopituitarism and adrenal disorder. Most recently, the patient was admitted to the hospital after experiencing atrial flutter and cardiac arrest at home but recovered and had mostly returned to baseline. During her hospital admission, she was placed on Nadolol (a beta blocker) 30 mg twice a day (BID) and Flecainide (an anti-arrhythmic) 25 mg (1.3 mL) BID via gastrostomy tube (G-tube). At discharge, the hospitalist ordered her to wear a transtelephonic Holter monitor to evaluate any additional arrhythmias. Upon discharge from the hospital, the patient was admitted to the home healthcare agency for 24-hour continuous home nursing care. During the home healthcare admission, the mother (patient's guardian) changed the patient's code status from a Do Not Resuscitate (DNR) to a Full Code. The mother's rationale for updating the patient's code status was her belief that her daughter was now medically stable and had been cancer-free for almost a year. The code status was changed despite the mother being told during the previous hospital admission that the patient's life expectancy would be less than six months. The home healthcare agency's admission assessment, completed by the clinical supervisor, noted the patient's rehabilitation potential to be "poor" and that her overall prognosis was "poor" as well. The insured RN reported to the patient's home the morning following the patient's admission to home healthcare. The RN had cared for the patient previously and was familiar with her medications and daily routines. Prior to starting his shift, the night nurse gave him a report on the patient's current status and the updated plan of care, including the new medications. The RN correctly noted the new medication orders for Nadolol 10 mg BID and Flecainide 25 mg (1.3 mL) BID via G-tube. At 8:00 a.m., the RN administered routine medications to the patient and performed her morning care. Between 9:45 a.m. and 11:45 a.m., the RN continued to provide routine patient care. At 12:00 p.m., the RN administered Flecainide and Nadolol, as well as other routine medications. However, instead of administering 25 mg (1.3 mL) of Flecainide as ordered, he administered 25 mL, which was approximately 19 times the prescribed dosage. At approximately 2:00 p.m., the RN identified changes in the patient's heart rate and vital signs. He noted that the patient was bradycardic with a weak pulse and unable to be aroused. The RN called the patient's mother at work to report the changes in her condition. The mother advised him to call the patient's cardiologist about the change. The RN contacted the cardiologist and was advised to call 911 for an ambulance to take her to the emergency department (ED). When the ambulance arrived, the RN gave a brief report of the patient's medical history and the medications he had given the patient that morning, which included Flecainide 1.3 mL. At this time, the RN realized that he had administered the incorrect dosage. The RN called the patient's mother and advised her of the medication error (administering 25 mL of Flecainide instead of 1.3 mL). The RN proceeded to the ED and arrived approximately 10 minutes after the ambulance. The RN informed the ED providers of the medication error, and a serum toxicology test was ordered to confirm the error. The patient was admitted to the intensive care unit, and despite all life-saving efforts, she died soon thereafter. Following the patient's death, the mother (plaintiff) filed a lawsuit against the insured RN and the home healthcare agency. The allegations against the RN included: Failure to properly administer the correct and prescribed dosage of Flecainide to the patient and a conscious disregard of the known risk of Flecainide toxicity and overdose; Administering an improper, excessive dose of Flecainide medication in an amount more than 19 times the prescribed dosage and with a conscious disregard of the known risk of Flecainide toxicity and overdose; Failure to review, confirm and/or adhere to the prescribed documentation regarding the medications; Failing to confirm and/or verify the correct dosage of Flecainide that was prescribed to be administered to the patient; and Failure to adhere to proper policies, procedures, and/or guidelines regarding the administration of prescribed medications to the patient. Duty:

Breach of Duty:

Causation:

Injury or Harm:

Are all four elements met? Is there a court case for malpractice?

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