Dr. S greeted the patient, who was greatly relieved to see a familiar face. They discussed her symptoms, and Dr. S examined her. He agreed with the gastroenterologist’s suspected diagnosis and discussed both conservative management and surgical options with Mrs. P. They decided that laparoscopic surgery was the best option.  

“I can’t tell you how grateful I am that you came to see me,” Mrs. P told the physician. “You have no idea what a comfort it is.”

Dr. S could see, however, that the patient was in a great deal of pain. After assessing her pain management, he decided that the dose of narcotic that had been prescribed for Mrs. P’s pain was inadequate.


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“Don’t worry, I’ll get you something to help with the pain,” he told her. “And I won’t leave for vacation until you’re comfortably in recovery,” he assured her. The patient expressed her gratitude. 

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Dr. S wrote a new order for pain relief for Mrs. P. He intended to write the prescription for Demerol, but since he was speaking to the patient while writing he became distracted and inadvertently prescribed morphine at the same dose that he would have prescribed the Demerol – 150mg intramuscularly.

As the physician was walking out, a nurse stopped him and questioned the dosage.

“Don’t you think that’s a large dose?” asked the nurse. “I don’t think we’ve given a dose like that here before.”

The physician, believing he had written the prescription for Demerol explained to the nurse that because the patient was a large-sized woman with muscle bulk, a larger dose was required. The nurse accepted this, and the patient was given the morphine – which was ten times the appropriate dose (but would have been the correct dose for Demerol).  

Dr. S realized there was a problem when he visited the patient in pre-surgery and saw that she was overmedicated. When he looked at the patient’s chart, he realized the error that had occurred.

The surgery, a laparoscopic appendectomy to remove an acute gangrenous perforated appendix, was eventually successfully performed and the patient did not suffer any long term adverse effects from the drug error, although it could have been lethal.

Dr. S felt terrible. He had never made such an error before. And to have it happen to someone he knew, made him feel all the worse. As soon as the patient was awake, he went to her room and explained to her what had happened.

“I’m so very sorry you had to experience that,” he said, very sincerely. “I can’t begin to tell you how awful I feel about this. I apologize from the bottom of my heart.”

The patient accepted his apology, and did not consult with an attorney to look into legal options.