Dr. F, 58, was a nephrologist with a busy practice in a large city. One of his patients was a 72-year-old woman, Mrs. D, who was on dialysis. Mrs. D’s condition was poor and she was admitted to the hospital for a foot amputation.

While visiting her in the hospital, Dr. F began writing a prescription for 10 mmol of potassium for the patient. He was interrupted while he was writing, and when he went back to it afterwards, he rethought the dosage and decided to make it 20 mmol instead. However, rather than start with a fresh prescription, or cross out what was already written, Dr. F attempted to write a number “2” over the “1.”

After he left the hospital, the nurse and pharmacist misread the prescription, believing that it read 120 mmol rather than 20. The prescription was filled for 120 mmol of potassium. Within 12 hours, Mrs. D was dead.


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When Dr. F was notified about his patient’s death, and the circumstances surrounding it, he was flabbergasted. He was called into the hospital as part of the administration’s investigation into Mrs. D’s death. “I may have been a little messy when I wrote the prescription,” he admitted, “but it went through a pharmacist and a nurse before the patient received it. How could the nurse and pharmacist not have realized that a 120 mmol dose of potassium is fatal?”

Doctor refuses to settle

Within a few months, both the hospital (as the employer of the nurse and pharmacist) and Dr. F were sued for malpractice by Mrs. D’s family. The hospital settled out of court for an unspecified amount, but Dr. F did not want to settle.

“Even if I was a little sloppy in writing the script,” he told his defense attorney, “there were at least two other healthcare professionals who should have caught it before it ever reached the patient. And if they couldn’t read what I’d written, why didn’t they call me?” The defense attorney reluctantly agreed, and the case proceeded to trial.

At trial, the plaintiffs (the three adult daughters of Mrs. D) testified about the anguish that their mother’s untimely death had caused them. Their attorney presented witnesses who testified that despite her health conditions, Mrs. D might have lived six or more years. In his closing argument, the attorney urged the jury to punish Dr. F, saying “these errors are happening on a daily basis, but are a dirty secret that often gets swept under the rug. You the jury, with your verdict, can suppress or encourage this type of behavior.”

The plaintiffs asked for $1.25 million for loss of companionship and mental anguish, $250,000 for Mrs. D’s pain and suffering, and $19,000 for funeral expenses.

The defense introduced experts who estimated that due to Mrs. D’s poor health, which included coronary artery disease and other ailments, she would only have lived six months to a year at most. Other experts testifying for the defense explained the roles of the pharmacist and nurse, and how the hospital employees should have had safeguards in place to ensure such an error did not happen. Dr. F testified that although he was very sorry for the outcome, he could not in his wildest imagination have thought that a dosage that high would be taken seriously by trained professionals. The defense attorney argued that the dosage was so outside of the norm that the pharmacist and nurse had a duty to call the physician before filling it.

The jury deliberated for two days before finding Dr. F negligent. The jury awarded the family a total of $380,000: $250,000 for Mrs. D’s pain and suffering, $110,000 for loss of companionship, and $20,000 for funeral expenses. The jury, however, also determined that the hospital was 90% at fault and Dr. F was only 10% at fault.