Case Outcome 3

Do you think the nurses met the standard of care?

Anaphylaxis is a serious, potentially life-threatening allergic response that is marked by swelling, hives, decreased blood pressure and dilated blood vessels. In severe cases, the patient can go into shock which can be fatal. Anaphylaxis occurs when the immune system develops a specific allergen fighting antibody (called immunoglobulin E or IGE) that initiates an exaggerated response in the body. When exposed to the substance later, the body can produce a large amount of histamine which leads to the development of the symptoms above. It may begin with itching of the eyes and face then progress, within minutes, to difficulty breathing and swallowing, abdominal pain, vomiting, diarrhea and hives. Medications are known causes of anaphylaxis.

Ancef or Cefazolin is a cephalosporin antibiotic used to treat many types of bacterial infections. Although it is in a different class of drugs from Penicillin, cross-sensitivity reactions can occur in up to 10% of patients. Caution and careful observation are advised when administering Ancef to a patient with a Penicillin allergy. If any signs of an allergic reaction occur, the nursing plan of care includes immediate discontinuation of the Ancef and notification of the physician. The physician may then order epinephrine and other emergency measures such as Oxygen, IV fluids, IV antihistamines, Steroids, Blood pressure medications and airway management.

The lawyer hired a nursing expert to review the medical records and provide opinion on whether or not Nurse Belinda and Nurse Winnie breached the standard of care. The nursing expert emphasized that medication administration is so much more than a task to be completed. It requires critical thinking, skill and nursing knowledge. She further stated that nurses must be knowledgeable of the actions, side effects and contraindications of all medications they administer. She stated that Penicillin and Ancef are two commonly administered medications in the hospital setting, so it was expected that Nurse Belinda and Nurse Winnie would be knowledgeable of their potential for cross reaction.

Based on this, the nursing expert determined that the nurses failed to meet the standard in three areas; failing to question the physician for ordering Ancef, administering Ancef to a patient with a serious Penicillin allergy without providing careful monitoring and failing to intervene to signs of an allergic reaction shortly after 1:00 a.m. when Elizabeth was rubbing her eyes and scratching her arms. All of the experts who reviewed the case stated that nursing and medical intervention at 1:00 a.m. would have most likely prevented Elizabeth’s death.

When the nurses were asked if they know of the potential for cross reaction, they responded that they did not. They said that because the doctor knew of Elizabeth’s Penicillin allergy, and ordered Ancef anyway, they assumed that it was safe to give. They were simply following doctors’ orders. Their lack of knowledge coupled with the failure to recognize and respond to early signs of an allergic reaction provided little defense in the lawsuit. This case settled out of court. Both Nurse Belinda and Nurse Winnie were disciplined by their professional body, required to take a course in safe medication administration and undergo a period of supervised practice.

Use this case study to spark a conversation about medication administration with your colleagues. Do you think the doctor was also responsible for this medication error? What are your thoughts on one nurse administering a medication that another nurse has prepared? How would you rate the safety of medication administration in your workplace? Have you ever witnessed or made a medication error? Did the patient suffer as a result? What is the process for reporting a medication error in your workplace? Does the process allow for open discussion, learning and improvement? If not, what can you do to promote safer medication practices? What will you do differently now that you know what you know? Want to learn more? Watch for one more article coming up!

This article was written by Chris Rokosh RN, PNC(C), Legal Nurse Consultant and president of Connect Medical Legal Expert. Chris is a popular speaker on legal issues in nursing across Canada and the US. If you want to learn more about this topic, go to the website for a list of available courses.