My Most Memorable CLNC Case involved the death of an elderly patient receiving palliative home care for chronic pain. The death occurred following the unauthorized alteration of a prescribed fentanyl patch by the home health nurse. This case illustrates how a well-intentioned but clinically unsound nursing decision can result in catastrophic harm.
Deviations from the Standards of Care
During a home visit, the nurse determined that the patient appeared excessively lethargic and independently attempted to reduce the prescribed dose of the fentanyl patch by cutting it in half. Deviations from the standards of care include:
- Altered the medication without authorization. The nurse inappropriately cut a controlled-release fentanyl patch in half. According to the manufacturer guidelines, fentanyl patches should not be cut or altered. Compromising the integrity of the patch may result in uncontrolled fentanyl delivery and create a risk of overdose, respiratory distress and death.
- Acted outside the scope of nursing practice. Adjusting a prescribed dosage and delivery method without a medical order or an authorized medical protocol is not within the nurse’s scope of practice.
- Failed to respond appropriately to excessive sedation. The nurse should have performed a focused assessment, notified the prescribing provider and followed escalation procedures.
Defense Arguments
The defense focused on causation issues. They argued that the patient’s underlying respiratory insufficiency and other comorbidities contributed substantially to the death. They also characterized the nurse’s actions as a benevolent intent to protect the patient from over-sedation rather than a willful disregard for patient safety. This defense is flawed because good intentions do not establish adherence to the standards of care.
CLNC® Services Provided
As the Certified Legal Nurse Consultant for the plaintiff attorney, I provided the following services:
- Screening for merit: I reviewed and analyzed the home health nursing records and the autopsy report to confirm the clinical relationship between the altered patch and the patient’s subsequent respiratory arrest and death. I isolated the most consequential nursing note, indicating that the nurse “cut patch in half to decrease dose.”
- Literature search: I provided authoritative literature and manufacturer warnings regarding fentanyl transdermal systems. The research established that fentanyl patches should not be cut or altered and helped explain the potential consequences of doing so.
- Chronological timeline: I created a detailed chronology of the nurse’s visit, the alteration of the fentanyl patch and the subsequent respiratory arrest. The chronology supported the temporal relationship between the nurse’s actions and the adverse outcome.
- Testifying expert liaison: I identified and briefed a pharmacological expert to testify on fentanyl pharmacokinetics and transdermal drug delivery.
Case Outcome
This case resulted in a significant out-of-court settlement in favor of the plaintiff’s estate. My analysis revealed that the nurse had documented “Cut patch in half to decrease dose.” This evidence made a defense of the facts nearly impossible, leading to the rapid settlement. The attorney shared, “Your ability to translate the complex pharmacokinetics of transdermal delivery into a clear narrative of negligence was the turning point in our negotiations. We couldn’t have secured this result without your clinical roadmap.”
Professional Business Impact
This case strengthened my reputation as an expert in medication errors and home health nursing standards. From a business perspective, this case became a turning point in my CLNC business. The revenue and professional momentum generated by the case allowed me to transition from part time to full time.
Lessons for CLNC® Consultants
- Examine the reasoning behind the deviation. Nurses rarely deviate from the standards of care because they intend to harm a patient. More often, the deviation arises from incomplete knowledge or flawed clinical reasoning. The nurse believed she was reducing the patient’s exposure to fentanyl. Understanding the reasoning behind a deviation helps you anticipate the potential defenses.
- Education is key. Attorneys may not recognize why a clinical action is dangerous. Your value lies in explaining the “Why.”
- Always ask what would I do differently next time. In retrospect, I would request the nurse’s personnel file and training records earlier in the discovery phase. Establishing a history of poor medication competency or lack of supervision within the home health agency could have potentially supported claims against the home health agency for systemic deficiencies.
Impact on the Plaintiff’s Family
My work product contributed to justice and accountability. While the settlement cannot replace their loved one, the legal recognition of the deviations from the standards of care provided closure for the family. It also impacted the home health agency’s policy to implement mandatory retraining for all staff regarding high-alert medications. The family responded positively knowing that the corrective action could help prevent a similar event from happening to another patient.
Guest Blogger Profile
Roxanne Bliss, MSN, APRN, FNP-C, CLNC, of Connecticut, is the owner of Valiant Med-Legal Consulting LLC, an independent Certified Legal Nurse Consultant and board-certified Family Nurse Practitioner with more than 35 years’ experience in emergency, cardiology, critical care, wound care, behavioral health, healthcare leadership, and VA Compensation & Pension examinations. Her background in clinical practice, program development, accreditation, and healthcare quality provides a systems-level perspective on medical malpractice, personal injury, toxic tort and VA disability cases for both plaintiff and defense attorneys.
