The licenses of two nurses working in a Pennsylvania hospital were recently suspended. The nurses cared for patients alleged to have died in a patient-dosing scandal perpetrated by a well-respected physician now facing criminal charges. The doctor is alleged to have contributed to the deaths of 35 patients in his care between 2014 and 2018.
The state nursing board suspended the licenses of the two nurses because both failed to question the high doses of Fentanyl and Versed being given to patients. Some pharmacists have also received disciplinary measures from their licensing agencies.
The two nurses testified to the nursing board about how they had trusted the doctor, and that he had done amazing things to try and heal patients that other doctors would not or could not do. One of the nurses reported that as a result of the post-traumatic stress he has experienced due to the situation, he felt forced to move to another part of the country.
Another nurse who was also accused of failing to question high dosage of Fentanyl turned in her nursing license.
The hospital was fined $400,000 by the Pennsylvania Board of Pharmacy and has paid over $13 million to settle lawsuits that have been filed due to the scandal.
Compliance Perspective
Failure to monitor high doses of medications like fentanyl which can cause death in patients may be considered a violation of residents’ rights to be free from significant medication errors. The facility’s failure to train its nurses to question and report on dangerously high doses of prescriptions like fentanyl could place the licenses of both the nurses and the facility in jeopardy. Additionally, the facility could be fined, sued, and considered as providing substandard quality of care, in violation state and federal regulations.
Discussion Points:
- Review policies and procedures for ensuring that dosages of medications are monitored and that protocols for medication administration include requiring nurses to question dosing of any medication that is out of the normal therapeutic range. Ensure that the pharmacy protocols include performance of ongoing reviews of drug regimens at the time a medication is ordered as well as monthly to discover potential patient overdosing.
- Train nursing staff to question the ordering physician and immediately report instances where high dosages of medications are being prescribed to their supervisor, the medical director, or through the facility’s Hotline.
- Periodically audit the dosage level of residents’ prescribed controlled medications.
