The Nurse and Doctor – Avoidable Medical Malpractice Case

Nora Walsh was a young nurse who lived in
a two-story house with her parents, in Pittsburgh, Pennsylvania. She had two jobs – a full-time
job in the Emergency Department and a part-time job as a nursing tutor. She took pride in
her love of science and decided to name her two small Pomeranians – Pen and Vanco, after
2 types of antibiotics – Penicillin and Vancomycin. One day, after wrapping up a tutoring session,
she went straight to the Emergency Department to do a night shift. In the early morning hours of her shift, a
patient – Parviz Elagin – was brought in by his husband. Parviz’s skin was covered in
hives, his face was swollen, and he was having difficulty breathing. Dr. Arturo Reyes screamed
from the other side of the room: “He’s got severe anaphylaxis! Let’s grab the crash
cart – we need the Endotracheal tube, epi, and IV fluids! Nora, I need your help on this!”
Nora left her coffee and rushed over to get the crash cart. A few seconds later, she was at the bedside
quickly opening up the drawers to get access to everything and rubbing her hands together
with hand sanitizer. “Here you go doc,” Nora said as she passed the endotracheal tube
to Dr. Reyes. “Nora… I need you to…” Dr. Reyes was trying to tell her something
while he was struggling with the intubation. It was clear – the patient’s larynx was
too narrow for this size of the tube. After several failed attempts, Dr. Reyes pulled
out the tube and said, “Nora, I need you to get me another tube – We need a smaller
diameter. ” Nora rushed. A few minutes later, the intubation was complete and everyone in
the room took a collective deep breath. But Parviz was still critically ill and his blood
pressure was starting to drift down – a worrisome sign of shock. “Give him 2 milliliters of
epinephrine,” Dr. Reyes ordered. Nora looked at Dr. Reyes in a strange way, like something
was clearly wrong, and asked: “Are you sure, Dr. Reyes?” “Yeah, let’s do this, he
needs epi in his system. And if he doesn’t respond then I want you to give him 2 more.” Nora grabbed the vial of epinephrine in the
cart which had a concentration of 1:1000, and delivered 2 milliliters which works out
to a dzose of 2 milligrams. A couple of moments later, the patient began to experience chest
pain and heavy breathing. His blood pressure shot up fast – 200/120. Nora and Dr. Reyes
looked up the ECG monitor and saw the same thing. “He’s experiencing severe tachycardia.
We need to do something!” Nora shouted. Unfortunately, the rapid change was too dramatic and within
moments the patient died. Dr. Reyes stared in shock and realized that
he had said 2 milliliters, but that he had assumed that the vial of epinephrine had a
concentration of 1:10000. He wanted to give a dose of 0.2 milligrams rather than 2 milligrams.
He had ordered Nora to give ten times more epinephrine by mistake. Nora and Dr. Reyes
explained what happened to Parviz’s husband Elon who was stunned and horrified. Within a few months, a lawsuit was brought
against the hospital and both Nora and Dr. Reyes were named specifically because they
ordered and delivered the medication that ultimately led to Parviz’s death from the
epinephrine overdose. Now – to rewind this back – let’s imagine
that Nora had precisely asked Dr. Reyes about the epinephrine dose, rather than the volume
of the medication. She could have repeated the dose out loud when she was noting it in
the patient’s chart, and also when she was about to inject it. This way, Dr. Reyes would
have probably noticed the high dose that he ordered, and he would have reduced it to 0.2
milligrams. The moral: Request medications in terms of amounts rather than volumes. Verbal
orders should be written down and repeated back and confirmed – even in an emergency.

5 thoughts on “The Nurse and Doctor – Avoidable Medical Malpractice Case

  1. I really like these lawsuit videos. They are extremely useful. I think this is the most didactical way of learning medicine. Thank you so much, Osmosis 🙏❤️

  2. Medics in the ER work in highly stressed environment. Besides they already know this information, but in practice, after a while it becomes normal for them. In the end, he dies and thats it. So, know this, it can get messy in there and be carefull.

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