Medication Incident Report Is Subject To Civil Discovery, Court Rules

Legal Eagle Eye Newsletter for the Nursing Profession

August 1996  

   Civil discovery is the pre-trial procedure by which the parties to a civil case, through their attorneys, use the mandatory judicial processes outlined in the rules of civil court to obtain relevant information for use in proving their cases at trial. Discovery includes requests for production of documents, subpoenas for records and depositions of eyewitnesses and experts.

   The U.S. District Court for the Western District of Arkansas has ruled that copies of hospital medication incident reports can be obtained through the civil discovery process by the plaintiff’s attorneys in a professional negligence case alleging improper administration of medication to a patient by a registered nurse.

   In this case, a nurse apparently gave her patient Phenergan IV instead of IM, at 2:00 am. The physician had ordered it 50 mg. IM p.r.n. for nausea. At 2:30 am the patient’s mother told the nurse he was not breathing properly, but no one checked him until 7:30 am. He had to be transferred to the ICU at a regional medical center, where he spent seventeen days in a coma.

   Hospital policy required the nurse to prepare and file an incident report for any variance between the physician’s order and the actual manner of administration of any medication. The incident report was extensively reviewed by the hospital’s clinical medical review committee.