On October 25, 2011, the plaintiff, age 53, was recovering from surgery at the defendant hospital. The surgery was uneventful and he was doing well postoperatively. The nurse changed the bag of his epidural pain medication, Ropivicaine (Naropin), which was prescribed for 8 mL per hour; the bag was supposed to infuse over the next twelve hours. However, the nurse mistakenly set the controls and the entire bag was infused in one hour. Following the overdose, the plaintiff was paralyzed up to his clavicle. He has regained some sensation and movement but his remaining paralysis is permanent.
This serious and life-threatening medication error could have easily been prevented had the hospital required nurses to double check and verify high-alert medications administered to patients via an epidural catheter. Such double checks are well-recognized. The Joint Commission has required that hospitals use a double check system for over a decade. Further, medication safety organizations, such as the Institute for Safe Medication Practices, also recommend use of a double check system for medication administration.