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Nurse Confuses Paralytic for Antacid;

Fails to follow safety protocols

David W. Hodges
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Partner at Kennedy Hodges LLP practicing pharmacy error, medical malpractice and personal injury law

Patient medication mistakesHundreds of medication errors are caused by similar-sounding drug names. The family of a 79-year-old man killed by this mistake wants to know why a paralytic – the same kind used in anesthesia before surgery for intubation and for lethal injection in death penalty cases – was on the floor of a non-surgical ward, and why the nurse mistook it for an antacid.

Richard Smith died after a nurse allegedly administered the wrong medication in his IV and now his family is suing that nurse in an effort to seek justice.
Nurse administers paralytic instead of Pepcid
After receiving a dialysis treatment, Smith was admitted to the ICU at North Shore Medical Center in Miami for shortness of breath. Smith complained to doctors about an upset stomach and the doctors prescribed Pepcid, an over-the-counter antacid.
According to reports, a nurse opened a locked drug cart and grabbed Pancuronium Bromide instead of the prescribed Pepcid. The nurse allegedly injected the medication into Smith’s IV and left the room.

Pancuronium acts as a muscle relaxant and paralytic and is used when intubating patients in surgery. Large doses of Pancuronium are used on inmates being put to death.

Smith was found unresponsive almost 30 minutes later. Although doctors resuscitated him, Smith remained in a vegetative state until he died a month later.

Nurse failed to follow several safety protocols.
According to a report from the Florida Agency for Health Care Administration, the nurse would have had to ignore nearly all of the safety protocols in place for administering drugs, including:

  • failing to check the medicine label, 
  • failing to scan and match the medication with the patient ID bracelet,
  • failing to follow drug cart dispensing safeguards.

In addition, the report says, the pharmacy wasn't able to show any justification for storing pancuronium in that particular area of the hospital.

Nurse still working on same hospital floor.
The nurse involved was reportedly fined $2,800, reprimanded, and required to go through remediation courses and retraining. He is still working in the hospital, on the same floor.

There are many questions left unanswered in this case, and the outcome, is of course, unknown at this time. We can only hope some justice is delivered to the family of Richard Smith, and that paralytics are removed from all floors except surgery suites and the emergency department.

If you want to learn more about taking action after a pharmacy or medication mistake, order our free book, How to Make Pharmacies Pay for Your Injuries Caused by Medication Errors. You can also contact our office at 888-526-7616 to have our pharmacy error attorneys review your case for free.