A Legal Nightmare: Denver Nurses Indicted in Newborn Death

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A Legal Nightmare ---Denver Nurses Indicted


Karren Kowalski, PhD, RN, FAAN

Marianne D Horner, MS, CNM

MCN, The American Journal of Maternal/Child Nursing

May / June 1998

Volume 23, Issue 3

CE Hours: 1.50

When does a mistake by a nurse constitute criminally negligent homicide? The authors of this article assisted defense attorneys on a recent case in Denver in which three nurses were indicted on the charge of criminally negligent homicide when a medication error resulted in the death of a healthy newborn.


6,620 Posts

That is absolutely sick. What do prosecutors think will be accomplished by charging nurses criminally for errors? And why are other health professionals like pharmacists immune?

nightingale, RN

2,404 Posts

This is so insane.... and yes, sick....


1 Article; 5,758 Posts

The law enforcement agencies that go after these nurses are crazy. There are enough reasons to avoid going into nursing. It is wierd that a series of errors are made resulting in a nurse actually giving the wrong drug but nurse alone is considered guilty. It is however a trend. It appears that the syringe was mislabeled. What I am not sure of is if any punishment was ever metted out to pharcacist or physicain.


104 Articles; 5,349 Posts

Specializes in Gerontological, cardiac, med-surg, peds.

In this case, if I recollect correctly, a doctor's sloppy penmanship was partially to blame (the pharmacist mistook a kindergarten-quality physician scribble "U" [for 'units'] for an '0,' contributing to the error, making the penicillin G dose 10X stronger than he intended. When the NNP changed the route of this drug from IM to IV, this mistake turned lethal.).. WHY IS NOBODY ADDRESSING THIS--MAKE THE DOC's TYPE THEIR ORDERS, ALL THEIR SCRIPTS, ETC. PUT AN END TO THIS PHARMACEUTICAL 'RUSSIAN ROULETTE'!!!!! If they're crazy enough to charge these poor devastated nurses with MURDER, then they also need to charge this doctor as an ACCESSORY TO MURDER for his illegible handwriting!!!!:(:(:(:(:(:(:

It'll always be the nurses fault. Not the docs, not the pharmacy, not administration.:o It always boils down to us and no one will have our backs.

I wish they would have checked the dosing.:o

Home Health Columnist / Guide


11 Articles; 18,056 Posts

Specializes in Vents, Telemetry, Home Care, Home infusion.

I find it irronic that in this case and Potassium error NEOFAX supposedly was consulted to verify dosing.

live4today, RN

5,099 Posts

Specializes in Community Health Nurse.

You know what? Several years ago, I read about Colorado trying to enact a law where nurses would be prosecuted if they caused the death of a patient. Pleas were being sought from nurses around the United States to write their congressmen and fight this act from being legalized. Now, here it is in living color for all the world to read...nurses being charged criminally for the death of an infant. If it becomes a possibility there, it will become a reality everywhere else. Are you writing those congressmen yet??? ;)


1,334 Posts

Specializes in NICU.

Does anyone know?

If the 10x drug dose HAD been given IM, would it still have been fatal?

SharonH, RN

2,144 Posts

Specializes in Med/Surg, Geriatrics.

That's outrageous! Reading that case made me sick. The pharmacist got off scot-free, the physicians who also made errors were not even smacked on the hand and the nurses are brought up on charges. Yes, they made a serious error but I have seen much worse errors than this made! Now people who are in a profession to help others face criminal prosecution if they make a mistake. This is unacceptable, people.


921 Posts

I read this case when it first came out in 1998. It was my feeling that the District Attorney did not understand what the role of the Nurse Practitioner was. He didn't seem to know that she was acting under the legalities of her license. The DA was an idiot!


1 Article; 2,394 Posts

Specializes in Everything except surgery.

Although I believe this was a witch hunt on the part of this citie's DA, and I totally believe that the MDs, and Pharmacist should have been bought up on charges just as they pulled in the Mother baby nurse....BUT...and I realize this will NOT be a popular view...I submit my opnion anyway.

I totally feel sorry for all the nurses in this matter...and DO NOT fell they should have been accussed as they were of that particular charge....BUT I do feel they were negligent in giving that med....especially since they were

1. Not familiar with how to give the drug.

2. Realized it was an exceptionally large dose

3. Did not contact the Pharmacist AND the Neonatologist and ANYONE else who could have maybe stopped this before it happened.

4. Just the fact that they would have to give (5) FIVE different injections should have set off enough alarm to make them go to more than just a DATABASE to get answers.

I'm appalled that NO ONE tried to get ALL the records on this pts OB records! I'm totally appalled that the neonatalogist didn't even consult with her OB!

I'm appalled that the pharmacist didn't contact the neonate DR on this order! It just boogles the mind that this error occured.

I recently worked on a unit and was supposed to give an IVPB. I checked and rechecked the order, and noticed that the dose was incorrected on the syringe prepared by the pharmacy. I also noticed that the med had been given several times at least by several shifts! The RN I worked with reported the error to the pharmacy, but she did NOT report the previously wrong does being given to this pt.

I also have worked on a unit where the wrong dose was ordered for a pt. The dose just seemed to me to be too large, and I at the time I was a relatively new nurse. So I went to other more experinece nurses and asked them what they thought. I was told..."that is the dose the DR ordered, and that is a usual dose for these types of pts. This didn't sit well with me, so I went to the charge nurse, who also gave me about the same statement and tried to belittle my concerns. This dose amount still bothered me, so when the Charge nurse made a call to the MD on call...I had her ask about the dose amount of this drug for this pt. It turned out the amount had been written by a resident, and was several times the intended amount. The charge nurse instructed me to change the order on the cardex, and she would write the order as was the policy of that hospital. I changed the cardex to the ordered dose which was the usual dose I was accustomed to giving. Unfortunately,...the charge nuse DID NOT write the order she received from the MD that nite. The next day I received a call from the agency ...and the hospital was stating I had written MY OWN order! Thankfully I had remembered the MD who had been reached by the charge nurse and HE CONFIRMED that he indeed had received a call from the charge nurse and HAD ordered the dose I had written on the cardex, and given. WHEW!

The above is my rational for why I believe these nurses should have NOT given the that med to the infant BEFORE contacting everyone and anyone involved with that med being ordered and prepared. And even then I probably would not have given it as I have refused to give meds that I believe were not appropriate, and believe me it turned out to be the right thing to do.

And NO...I don't think I know it all....quite the contrary...but I do think I have a guardian angel, that has allowed me to keep out of trouble in these matters thus far....as there are many instances where I could have screwed up...but I thank GOD I have been spared thus far.

My heart does go out to these nurses...because I believe they probably thought they were taking every precaution...but I just fail to believe how they could have given this med without contacting more than just a database! I STILL DO NOT think they should be prosecuted in this situation....especially since they let others walk away free!

MY opinion only

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