Death Following Overdose - Hospital Injected Eight Times Prescribed Drug - $650,000 Settlement

27 Jul 2007

December 1998 Legal Case Study

The Decedent, a sixty-seven year old woman, was admitted to St. Margaret's Hospital on September 26, 1994, and was diagnosed as hypomagnesemic. She had been admitted to St, Margaret's the previous June in a similar weakened state. This time, her physician ordered forty-three milliequivalents of magnesium sulfate to treat her condition.

Due to errors involving four members of the hospital's pharmacy and nursing staff, decedent instead received forty grams of the medication by intravenous injection. Plaintiff claimed the chain of negligence began with a pharmacist who brought out a large forty gram bottle of magnesium sulfate to fill the prescription, then left for lunch. The next pharmacist just took the jar and used it.

The mistaken substitution of forty grams for forty-three milliequivalents was up to eight times the amount ordered by Majchrzak's physician.

The nurse administering the dosage noticed a disparity between the doctor's order and the label on the bottle and asked her supervisor what to do. Without looking at the order or the bottle, the head nurse told her the physician and pharmacist must have talked about the order and that she should go ahead and administer it. Neither of the nurses contacted the physician or the pharmacy, which would have been standard hospital policy.

Within hours, she suffered a cardiac and respiratory arrest, brain anoxia, and subsequent seizures. Two weeks later she was transferred to St. Francis Medical Center in Peoria, where she died on December 10. All four staff members, admitted their mistakes, but St. Margaret's initially fought the $2 million lawsuit filed by decedent's estate on grounds that the overdose was not the direct cause of her death since it occurred several weeks later. The case eventually settled for $650,000.