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Medico Legal Case Study Collection

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Health Care Supreme Court Cases

Early in the 21st century, health care has taken center stage for many Americans. The Affordable Care Act, popularly known as Obamacare, transformed the market for individual health insurance in an effort to expand access. The Supreme Court has heard several complex cases involving this law, which has weathered challenges so far. Meanwhile, the COVID-19 pandemic has fueled controversy over vaccination mandates. A pair of older Supreme Court cases illuminate that topic.

End-of-life decisions may raise difficult legal questions. Although a patient generally has a right to refuse medical treatment, the Supreme Court has allowed states to limit this right when the patient cannot clearly express their wishes. Moreover, a ban on assisted suicide may be compatible with the Constitution. A state that permits assisted suicide, on the other hand, may be entitled to be free from federal interference.

The Supreme Court also has addressed health care issues in areas as diverse as antitrust laws, drug safety, and religious freedom. Some health care cases implicate the doctrine of preemption, which provides that federal laws supersede conflicting state laws. For example, the Employee Retirement Income Security Act of 1974 (ERISA) generally preempts state laws related to employer-sponsored health plans.

Below is a selection of Supreme Court cases involving health care, arranged from newest to oldest.

Author: Clarence Thomas

The Department of Health and Human Services may promulgate exemptions to the Affordable Care Act to allow for-profit organizations to exempt themselves from the contraceptive coverage requirement on religious or moral grounds.

Author: John Roberts

Congress intended the tax credits authorized under the Affordable Care Act to be available through both state and federal exchanges.

Author: Anthony Kennedy

A non-sovereign actor controlled by active market participants enjoys state action antitrust immunity only if the challenged restraint is clearly articulated and affirmatively expressed as state policy, and the policy is actively supervised by the state.

Author: Samuel A. Alito, Jr.

The Religious Freedom Restoration Act (RFRA) permits a closely held for-profit corporation to deny its employees the health coverage of contraceptives to which the employees are otherwise entitled by the federal Patient Protection and Affordable Care Act, based on the religious objections of the corporation's owners. More generally, protecting the free exercise rights of closely held corporations protects the religious liberty of the people who own and control them.

Design defect claims based on generic drugs are preempted by federal law.

Author: Stephen Breyer

Reverse payment settlement agreements in the pharmaceutical industry are not per se illegal but should be analyzed according to the rule of reason.

The individual health insurance mandate under the Affordable Care Act was a permissible use of Congress' taxing power, but the way in which the ACA conditioned all Medicaid funding on states' compliance with a significant expansion was not a valid use of Congress' spending power. Also, the Commerce Clause gives Congress the power to regulate commerce but not to compel it.

Failure-to-warn claims based on generic drugs are preempted by the FDA's interpretation of federal drug regulations.

Author: John Paul Stevens

State tort law claims, such as failure-to-warn claims, are not preempted by the FDCA with regard to prescription drugs, but they are an additional level of safeguards for consumers that complements the goals of the FDA.

Author: Antonin Scalia

The Medical Device Amendments to the Food, Drug, and Cosmetic Act preempt state common-law claims challenging the safety or effectiveness of medical devices marketed in a form that received pre-market approval from the FDA.

Chevron deference is not accorded merely because a statute is ambiguous, and an administrative official is involved. A rule must be promulgated pursuant to authority that Congress has delegated to the official. Also, even if a drug falls within the Controlled Substances Act, a doctor can prescribe it for a patient if it is allowed in the context of assisted suicide for terminally ill individuals under state law.

State laws permitting the medical use of marijuana do not prevent Congress from prohibiting its use for any purpose in those states under the Commerce Clause.

ERISA prevents individuals from suing HMOs in state court for pure eligibility decisions. Also, if an individual at some point in time could have brought their claim under ERISA Section 502(a)(1)(B), and no other independent legal duty is implicated by a defendant's actions, the individual's cause of action is completely preempted.

Author: David Souter

HMOs may be insurers and thus subject to state regulation of insurers. State laws directed toward the insurance industry are saved from preemption under ERISA's saving clause.

Mixed treatment and eligibility decisions by health maintenance organization (HMO) physicians are not fiduciary decisions under ERISA.

Author: William Rehnquist

A “right” to assistance in committing suicide is not a fundamental liberty interest protected by the Due Process Clause. Thus, a state law banning physician-assisted suicide does not violate due process.

A state does not violate the Equal Protection Clause by banning assisted suicide while permitting patients to refuse medical treatment.

Author: Sandra Day O’Connor

The power to amend or abolish an employee welfare benefit plan does not include the power to discriminate against the plan's participants and beneficiaries for the purpose of interfering with their attainment of rights under the plan.

A law operating as an indirect source of merely economic influence on administrative decisions should not suffice to trigger ERISA preemption.

ERISA's deemer clause demonstrates Congress' clear intent to exclude from the reach of the saving clause self-funded ERISA plans by relieving them from state laws purporting to regulate insurance. State laws directed toward such plans are preempted because they relate to an employee benefit plan but are not saved because they do not regulate insurance.

The Constitution does not forbid a state from requiring that evidence of an incompetent person's wishes as to the withdrawal of life-sustaining treatment be proved by clear and convincing evidence.

A law prohibiting certain drug use is constitutional under the Free Exercise Clause if it is facially neutral and generally applied. More generally, the Free Exercise Clause does not relieve an individual of the obligation to comply with a law that incidentally forbids (or requires) the performance of an act that their religious belief requires (or forbids) if the law is not specifically directed to religious practice and is otherwise constitutional as applied to those who engage in the specified act for non-religious reasons.

For disclosure purposes, a “participant” in an ERISA plan means an employee in currently covered employment (or reasonably expected to be in currently covered employment), or a former employee who has a reasonable expectation of returning to covered employment or who has a colorable claim to vested benefits. To establish that they may become eligible for benefits, a claimant must have a colorable claim that they will prevail in a suit for benefits, or that eligibility requirements will be fulfilled in the future.

Author: William Brennan

To be preempted by ERISA, a state statute must have some connection with or reference to a plan.

ERISA preempts state common law tort and contract actions asserting improper processing of a claim for benefits under an insured employee benefit plan.

Horizontal agreements to fix maximum prices are on the same legal footing as agreements to fix minimum or uniform prices. More specifically, maximum fee agreements between medical societies and member doctors are per se illegal as price-fixing agreements under Section 1 of the Sherman Act.

Requiring healthcare providers to store the private information of patients who receive prescriptions for drugs that can be illegally abused is permissible, despite the privacy rights of the patients.

Author: Wiley Blount Rutledge

The government may restrict parental authority in the interests of child health and welfare.

Author: Louis Brandeis

City ordinances that require that students be vaccinated to attend school and that vest broad discretion in health authorities to determine when and under which circumstances such a requirement will be enforced do not violate the Fourteenth Amendment.

Author: John Marshall Harlan

A state may enact a compulsory vaccination law, since the legislature has the discretion to decide whether vaccination is the best way to prevent smallpox and protect public health. The legislature may exempt children from the law without violating the equal protection rights of adults if the law applies equally among adults.

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Physician and Pharmacist Liability: Medicolegal Cases That are Tough Pills to Swallow

John cs schupbach , md, mba, maria c kaisler , md, gregory p moore , md, jd, benjamin j sandefur , md.

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Address for Correspondence: John Schupbach, MD, MBA, Mayo Clinic, Department of Emergency Medicine, 200 First Street SW, Rochester, MN 55905. Email: [email protected] .

Corresponding author.

Received 2021 Jan 23; Revised 2021 Apr 3; Accepted 2021 Apr 10; Collection date 2021 May.

This is an open access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) License. See: http://creativecommons.org/licenses/by/4.0/

We present four medicolegal cases involving medication errors, which led to patient harm and subsequent settlements or jury awards to patients. These cases each involved scenarios in which a medication was inappropriately prescribed and/or inappropriately dispensed. In such cases, it is often not obvious whether the physician or pharmacist is at fault. These cases highlight the importance of understanding the roles and responsibilities of the physician and pharmacist in medication prescription and dispensation.

Keywords: Malpractice, medication error, prescribing, liability

INTRODUCTION

Physicians and pharmacists each have different roles and responsibilities in the process of safely prescribing and dispensing medications. Despite technology and systems designed to prevent harm, errors and oversights persist. The responsibility of an emergency physician to independently warn a patient of medication side effects is well established. A case that illustrates this duty is that of a woman with a history of migraines who had presented many times to the emergency department (ED) and received the same treatment regimen, which she had tolerated well previously. After receiving her usual treatment, however, she was discharged without being warned that the medicine could cause sedation. Shortly after discharge, she was involved in a motor vehicle accident that left her paraplegic. She litigated for “failure to warn” and was awarded $1.3 million. 1

Our intention in this article is to capture the nuances involved when both a physician and a pharmacist are involved, such as when a medication is prescribed by a physician and dispensed by a pharmacist. Although the cases we discuss below are not specific to emergency medicine (EM), the principles apply to medication prescribing and dispensing in an EM setting.

Case 1 - Lovecchio v Rosenthal

An 82-year-old man was discharged from the hospital after a cardiology admission. Upon discharge, the cardiologist prescribed outpatient amiodarone 1200 milligrams (mg) three times daily. A typical dose is 400 mg three times daily. The patient promptly filled the prescription. The pharmacist did not notice the excessive dose. At home, the patient took the first dose and four hours later suffered a cerebrovascular accident (CVA) that was later deemed by experts to be due to hypotension. He died 18 months later as a result of complications of the CVA. A lawsuit was filed claiming that the physician was in error for writing a prescription for 1200 mg three times daily and that the pharmacist should not have filled the prescription as written. A jury awarded a verdict of $1 million. The physician was responsible for $750,000, and the pharmacist was responsible for $250,000.2

Case 2 - Anonymous v Miller Pharmacy

A 67-year-old cancer survivor picked up her regular prescription for methadone that was prescribed as 15 mg (three 5 mg tablets) twice daily. Four days later, she was found dead. It was discovered that she had been dispensed 10 mg tablets in error. The technician had typed the wrong dose and the pharmacist did not notice the error. The pharmacy and pharmacist settled for $325,000.3

Case 3 - Quick v Acaylar, Parnell, and Marlboro Drug Company

A two-year-old female was prescribed ranitidine for gastrointestinal reflux by her pediatrician. After the pharmacist dispensed the medication at the prescribed dose, the child gradually developed tremors, shaking, ataxia, left eye deviation, and somnolence. Her parents litigated and claimed that their daughter was chronically overdosed with ranitidine. The usual dose was three-fourths of a teaspoon twice daily, and the child had been prescribed 3¼ teaspoons twice daily for 2–4 weeks. They claimed the pediatrician erred in prescribing that dose and that the pharmacist unsafely dispensed the medication. The pediatrician settled the case for a confidential amount. The pharmacist and pharmacy settled for $25,000.4

Case 4 – Anton v Brown

A 37-year-old man was prescribed methadone for opioid addiction by his physician. The dose was 60 mg twice daily for 10 days followed by 30 mg twice daily for 10 days. The pharmacist called the physician to report there were no 60 mg tablets. The dose was changed to 1.5 tablets of 40 mg tablets twice daily. No future reduction in dose was discussed. Federal law at the time limited dosing to a maximum of 40 mg total daily. The patient developed nausea but was unable to reach his physician. A call to the pharmacist resulted in instructions to continue the medication until the physician was contacted. The patient was found dead the next day. Autopsy cited the drug interaction between escitalopram and methadone, which had been recently prescribed by the primary physician. The physician settled the lawsuit for $1 million, and the pharmacist contributed another $900,000 to the settlement.5

Adverse Drug Events

These four cases illustrate different sources of medication dosing errors, each of which lead to detrimental harm. Unfortunately, medication errors are not as rare as we would hope. Approximately 1 in 20 patients is exposed to preventable harm, and 25% of such incidents are medication-related.6 The landmark report To Err is Human; Building a Safer Health System by the Institute of Medicine estimated medication errors cause 1 of 131 outpatient and 1 of 854 inpatient deaths.7 In a study of adverse drug events in the ambulatory setting, the medication classes most frequently involved in adverse drug events were selective serotonin reuptake inhibitor (SSRI) agents (10%), beta-blockers (9%), angiotensin-converting-enzyme (ACE) inhibitors (8%), and nonsteroidal anti-inflammatory (NSAID) agents (8%).8

Traditionally, pharmacists have been viewed as protected from the duty to warn patients about their prescribed medications; this duty has historically rested upon the physician and drug companies. This legal concept will be discussed further below. However, some courts have recently ruled that pharmacists do have a duty to warn, particularly in cases in which there are known contraindications or clear errors in the prescription (for example, excessive dosing, as demonstrated in the cases above).9

A 2013 retrospective review of pharmacist liability insurance claims from 2002–2011 by Health Providers Service Organization (HPSO), a national provider of professional liability insurance for more than 70,000 pharmacists, demonstrated 162 closed pharmacist and pharmacy technician claims. A claim is considered closed when all of the following criteria occur: there is a medication-related incident; there is an adverse patient outcome; a claim is filed against the insured pharmacist or technician; and there is payout on behalf of the insured party. Individually insured pharmacists accounted for 93.8% of closed claims. Wrong drug (43.8%) and wrong dose (31.5%) claims together represented 75.3% of all the closed claims in the study sample. Failure to identify overdosing encompassed only 3.1% of all the closed claims in the analysis. However, the average paid overdose indemnity was substantially higher than the overall average paid indemnity. All claims except one in the “failure to identify overdose” category involved opioids. 10

In a subsequent 2018 retrospective review sampling of HPSO pharmacist malpractice claims from 2012–2016, the annual number of closed claims more than doubled and the average total incurred payout per claim increased by 22.8%, to $124,407. While wrong drug and wrong dose errors continued to be the leading reasons for initiation of a claim, both decreased significantly relative to other causes with wrong drug claims accounting for 36.8% (from 43.8%) and wrong dose claims accounting for 15.3% (from 31.5%). These relative decreases are a result of large increases in other categories of allegations. 11

Although the specific percentage of “failure to identify overdosing” claims is not explicitly stated in the 2018 report, it occurred the “most infrequently of all closed claims in the analysis.” However, the average total incurred claim payout for such “failure to identify overdosing” claims was $544,600. This represents 167% more than the next highest category (compounding calculation and/or preparation error) and 337% that of the overall average payout of $124,407. Overdose also represented the leading cause of death in the sample, accounting for 73.7% of claims associated with medication-related patient death. 10

Medications and Interactions

To further explore and illustrate the complexity of even a single dosing error and interaction, we take a closer evaluation of Case 4, Anton v Brown . This case involves concerns for both an excessive initial dose of methadone and potential interaction between methadone and the patient’s ongoing escitalopram treatment.

Methadone is a μ-opioid receptor agonist and likely N-methyl-D-aspartate receptor antagonist that is approved by the United States Food and Drug Administration (FDA) for opioid detoxification and maintenance therapy of opioid use disorder. Opioid agonist treatment with either methadone or combination of buprenorphine and naloxone has been proven to safely and effectively suppress illicit opioid use and reduce the risk of death. 12 Methadone requires careful initiation, dose titration, medication changes, and discontinuation due to its pharmacokinetic properties, which vary widely from patient to patient. Characteristics that make methadone particularly difficult to safely administer include a long and highly variable half-life of 24–40 hours, a tendency for the medication to accumulate during initial treatment, and a risk of hazardous medication interactions. 11

Methadone is metabolized by cytochrome P450 isozymes. Therefore, cytochrome P450 inducers, such as antiretrovirals, rifampin, barbiturates, and phenytoin, can accelerate metabolism of the drug, leading to earlier withdrawal. Alternatively, cytochrome P450 inhibitors, such as fluconazole, ketoconazole, cimetidine, fluoxetine, paroxetine, ciprofloxacin, macrolide antibiotics, and grapefruit juice, can prevent methadone metabolism, causing higher methadone plasma concentrations than intended and increasing the risk of sedation and overdose. 11 Methadone has two primary hazards: respiratory depression and QT prolongation, particularly at higher doses. For these reasons, methadone is frequently administered as part of close monitoring programs —often daily—to ensure appropriate dosing and response to treatment. 11 Treatment is initiated when there are no signs of sedation or intoxication and the patient shows signs of withdrawal.

Methadone dosing of 20–30 mg (maximum dose 30 mg) is administered orally initially. In patients with a low expected tolerance (ie, have not taken opioids for more than five days), lower initial dosing is recommended. The patient is reassessed 2–4 hours after the first dose. If additional dosing is determined necessary, an additional 5–10 mg can be administered. The maximum recommended total daily dose on the first day of treatment is 40 mg. Over the first week, dosing is adjusted cautiously based upon control of withdrawal symptoms 2–4 hours after administration. Over time, maintenance therapy targets a dosage that prevents opioid withdrawal for 24 hours, generally 80–120 mg/day. During discontinuation of therapy, dosing is decreased slowly, by no more than 10% in 10- to 14-day intervals, to prevent withdrawal. 11

Escitalopram

Escitalopram is an SSRI and S-enantiomer of racemic citalopram. Escitalopram is approved by the FDA for the treatment of major depressive disorder. It functions by enhancing serotonergic activity in the central nervous system (CNS) as a result of its inhibition of serotonin (5-HT) reuptake in CNS neurons. 13

Escitalopram is metabolized by cytochrome P450 isozymes. 14 Although the specific isozymes differ from those used by methadone and neither methadone nor escitalopram are known cytochrome P450 inhibitors or inducers, the potential for unknown and unpredictable interactions does exist.

Numerous hazards of escitalopram have been reported, including serotonin syndrome, QT prolongation, and torsades de pointes. Furthermore, SSRIs as a class have been shown to increase the risk of suicidal thinking and behavior in children, adolescents, and young adults with major depressive disorder and other psychiatric disorders in short-term studies. However, in patients beyond age 24, short-term studies did not show an increase in the risk of suicidality with antidepressants compared with placebo. Furthermore, in patients 65 and older, there was a reduction in risk of suicidal thinking and behavior with antidepressants compared with placebo.

Escitalopram is contraindicated in patients with hypersensitivity to citalopram or escitalopram, as well as patients who received a monoamine oxidase inhibitor in the previous 14 days, as these can interact to cause serotonin syndrome. Escitalopram also has a long list of medication interactions. For instance, strong evidence supports contraindication with linezolid and major interactions with lithium, both due to increased risk of serotonin syndrome, and risk with concurrent NSAID therapy due to increased risk of bleeding. 12 A major drug-drug interaction warning exists between escitalopram and methadone due to concern for increased risk of both serotonin syndrome and QT prolongation. 12

Duty and Responsibility when Prescribing and Dispensing Medication

Pharmacists and physicians have separate duties when medications are prescribed and dispensed. Two cases clearly describe these respective duties.

The duty to warn patients of medication side effects rests with the prescribing physician. In Morgan v Wal-Mart Stores, Inc ., a 12-year-old boy was prescribed desipramine for attention deficit hyperactivity disorder. The prescribing physician testified that she had shown the patient’s mother common side effects of desipramine in the Physicians’ Desk Reference . Two years later, after multiple physician visits, the child died of hypereosinophilic syndrome, a rare but known complication of desipramine. The parents filed suit against Wal-Mart for negligence “by failing to properly warn intended users of the hazards and harms associated with the use of the product.” The court ruled that the prescribing physician was liable and that the pharmacist had no duty to warn of medication side effects. 15

Multiple other state courts have agreed that it is the physician’s duty to warn of these potential side effects. In Frye v Walgreen , the court ruled that pharmacists are not obligated to warn of all potential medication side effects. Simply placing warning labels on medication bottles does not imply that a pharmacist is accepting shared liability for a physician’s duty to warn. 16 This leads to a dilemma for physicians: “How can I logistically warn patients of every side effect for every medication I prescribe?” In the ED, this can be practically accomplished by delegating the duty to the patient to “read the package inserts of prescribed medications” when discussing and providing discharge instructions. It is imperative for physicians to consider these warnings carefully when they add new medications or change doses of existing medications.

Pharmacists, on the other hand, have a duty to safely fill prescriptions and can be held liable for adverse outcomes if a prescription that a reasonable pharmacist would deem to be unsafe is still filled and dispensed. In Brooks v Wal-Mart Stores, Inc ., the court ruled against a pharmacist who had filled a prescription for an excessive dose of prednisone (80 mg four times daily). The dose was confirmed with the physician at the time. The patient subsequently developed Nocardia pneumonia and cerebral aspergillosis. He underwent numerous surgeries and hospitalizations, ultimately developing renal failure. Despite confirming the initial dose with the physician, the pharmacist was nevertheless held solely liable for the medication error. The result was an award to the patient for $2.5 million. Although the physician is responsible for warning of side effects, the pharmacist must “exercise his [or her] own judgement as to whether any dosage prescribed, even if confirmed by the prescriber, would be harmful” and has an obligation to not fill a prescription he or she deems harmful. 17

We have presented four medicolegal cases involving medication prescription and dispensation errors that led to patient harm and subsequent settlements or jury awards to patients. These cases each involved scenarios in which a medication was inappropriately prescribed and/or inappropriately filled. Heretofore, it may not have been obvious to emergency care providers whether the physician or pharmacist is at fault. These cases have highlighted the importance of understanding the roles and responsibilities of the prescribing physician and filling pharmacist in medication prescription and dispensation. Although these legal cases do not originate in the ED, the legal principles hold true for ED practices. The above legal cases have established the legal duties of the physician who must warn and the pharmacist who must safely dispense. In some situations, these liabilities may be shared as noted in the cases above.

Take-home Points.

The physician has a duty to warn patients of side effects and interactions of medications.

The pharmacist has no duty to warn patients of side effects but does have a duty to safely fill and dispense prescribed medications, including ensuring that a prescribed dose is safe.

We recommend that a physician reduce liability by directing patients to read the packaging inserts of their prescribed medications.

“Wrong drug” and “wrong dose” claims are the most common medication errors leading to monetary awards among pharmacy malpractice claims.

“Failing to identify overdose” is associated with the largest monetary awards among pharmacy malpractice claims.

The most common medications involved in outpatient adverse drug events are SSRIs, beta-blockers, ACE inhibitors, and NSAIDS.

Section Editor: Melanie Heniff, MD

Full text available through open access at http://escholarship.org/uc/uciem_cpcem

The authors attest that their institution requires neither Institutional Review Board approval, nor patient consent for publication of this case report. Documentation on file.

Conflicts of Interest : By the CPC-EM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. The authors disclosed none.

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Court rulings that changed medicine

Key takeaways.

What happens when technology firms, insurance companies, healthcare systems, and even the US government encroach on medical practice? In short, the courts get involved.

Landmark Supreme Court cases and lower court rulings have set the tone on medical ethics and shaped healthcare policy. Here are five such cases that made their mark on medicine.

Vizzoni v. Mulford-Dera, 2019

In this case, the Superior Court of New Jersey Appellate Division upheld a trial court decision to dismiss a malpractice lawsuit after the family of a New Jersey woman who was killed during a car-bicycle accident sued the driver’s psychiatrist for medical negligence. The psychiatrist had been treating the driver, Barbara Mulford-Dera, for psychological conditions, and when Mulford-Dera struck and killed the cyclist, she had been taking a prescription medication that she allegedly did not know made it dangerous to drive. The bicyclist’s family maintained that the psychiatrist should have disclosed the potentially harmful effects of driving while under the influence of the prescribed psychotropic medication. But the trial court dismissed the case, ruling that it was not medical negligence. In an amicus brief, the American Medical Association warned that expanding physician legal obligations to the general public would have profound negative implications for medical professionals.

State of Washington v. US Department of Health and Human Services, 2019

In this case, a federal judge in Washington issued a nationwide injunction blocking a series of proposed abortion restrictions. The restrictions, issued by the Trump administration, would have barred federally funded family planning facilities from advising or assisting patients seeking an abortion. Facilities backed by federal funding under the Title X program, including Planned Parenthood, were already prohibited from using those funds to perform abortions, but under this so-called “gag rule,” they would no longer be able to say or do anything to assist patients who were seeking an abortion, including referring them for abortion procedures. The rule was promulgated in March 2019 by the Department of Health and Human Services, and blocked by a federal judge the following month. In support of the injunction against the proposed plan, Washington state Attorney General Bob Ferguson said that it “ensures that clinics across the nation can remain open and continue to provide quality, unbiased healthcare to women.”

National Federation of Independent Business v. Sebelius, 2012

In a Supreme Court ruling, a key provision in the Affordable Care Act (ACA), passed by Congress in 2010, was upheld. The ACA, created during the Obama administration, contained an individual mandate that required all Americans to buy health insurance or pay a tax penalty. It also required states to expand their Medicaid programs or risk losing federal funding. The court upheld the individual mandate on American citizens but rejected the provision to withhold federal funding from states that didn’t expand Medicaid, ruling that state participation in the program would be voluntary. “The Affordable Care Act’s requirement that certain individuals pay a financial penalty for not obtaining health insurance may reasonably be characterized as a tax,” Chief Justice John Roberts wrote in the ruling . “Because the Constitution permits such a tax, it is not our role to forbid it, or to pass upon its wisdom or fairness.”

Sherley v. Sebelius, 2010

In this case, a scientist from the Boston Biomedical Research Institute sued to block a 2009 executive order by the Obama administration that expanded embryonic stem cell research. Obama’s order limited federal funding to research on embryonic stem cells that would otherwise be disposed by fertility clinics. The scientist, James Sherley, argued that the order would exclude his team from federal funding with work on adult stem cells. A federal judge ruled in favor of Sherley, stating that the executive order violated a law that prohibits federal financing of any research in which embryos are destroyed. Medical experts have long regarded embryonic stem cell research as a beneficial methodology to better understand how diseases appear and progress. However, this research has been at the center of heated political and ethical debate because it involves the destruction of human embryos. Ultimately, the US Court of Appeals for the District of Columbia Circuit voted to overturn the judge’s ruling, and the Supreme Court declined to hear the case. Stem cell research continues to be fraught with debate and controversy.

Gonzales v. Oregon, 1994

Oregon became the first state to legalize assisted suicide after enacting the Death with Dignity act. The law permitted physicians to dispense and prescribe a lethal dose of drugs to terminally ill patients who were within half a year of death. In 2001, the US Attorney General John Ashcroft challenged the law, stating that it violated the Controlled Substances Act of 1970. Ashcroft threatened to revoke the medical licenses of physicians who took part in assisted-suicide procedures. The case was brought to the District Court and Ninth Circuit Court of Appeals, which sided with the state of Oregon. Then, the Supreme Court affirmed the Ninth Circuit’s judgment. Writing for the majority, Justice Anthony Kennedy concluded that the federal government could not delegitimize a medical standard authorized under state law.

These cases not only shed light on how Congressional power is exercised over medical practice and public health, they are also representative of how the fields of healthcare and government work together. Each case is a unique effort geared at finding the balance between constitutional rights and public benefit, while considering scientific and ethical progress.

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Pebley v. Santa Clara Organics

An insured plaintiff who has chosen to be treated with doctors and medical facility providers outside his insurance plan shall be considered uninsured, as opposed to insured, for the purpose of determining economic damages. The Court of Appeal held that the trial court properly allowed the plaintiff in this case, as a plaintiff who is treating outside his insurance plan, to introduce evidence of his medical bills. The trial court also permitted defendants to present expert testimony that the reasonable and customary value of the services provided by the various medical facilities was substantially less than the amounts actually billed. The jury rejected the expert evidence and awarded plaintiff the billed amounts. The court held that defendants have not demonstrated error except with respect to two charges regarding the amounts billed by Ventura County Medical Center and American Medical Response. Accordingly, the court reduced the damage award and affirmed the judgment as modified.

An insured plaintiff who has chosen to be treated with doctors and medical facility providers outside his insurance plan shall be considered uninsured, as opposed to insured, for the purpose of determining economic damages.

Disclaimer: Justia Annotations is a forum for attorneys to summarize, comment on, and analyze case law published on our site. Justia makes no guarantees or warranties that the annotations are accurate or reflect the current state of law, and no annotation is intended to be, nor should it be construed as, legal advice. Contacting Justia or any attorney through this site, via web form, email, or otherwise, does not create an attorney-client relationship.

Some case metadata and case summaries were written with the help of AI, which can produce inaccuracies. You should read the full case before relying on it for legal research purposes.

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How Trivent Legal’s medical illustration service enhance complex cases    

This case study demonstrates how Trivent Legal’s Medical Chronology , Hotlinks , and Medical Illustration services were applied to a challenging medical malpractice case involving a gallbladder surgery complication. Rachel Doe underwent laparoscopic gallbladder surgery but suffered severe post-operative complications, including bile duct damage, which complicated the case and raised critical questions of surgical negligence.  

Case Overview:  

Rachel Doe underwent a gallbladder surgery on XX-XX-XXXX . After a laparoscopic procedure, she was discharged. However, she returned to the emergency room with symptoms of jaundice. It was later discovered that the surgeon had either stapled or damaged her bile duct during the surgery. This injury led to ongoing complications, and Rachel Doe required additional medical care to address the damage.  

Legal Services Requested:  

The legal team needed a clear, organized, and comprehensive view of the medical events to demonstrate where the standard of care was violated. Trivent Legal provided:  

• Medical Chronology : A detailed timeline outlining the surgical procedure, pre-operative assessments, post-operative care, and subsequent treatments, organized by date and medical provider.  
• Hotlinks : These allowed the chronology to be easily navigated and cross-referenced with Rachel Doe’s medical records for seamless, rapid access to critical information.  

Trivent Legal’s Approach:  

We meticulously prepared a Medical Chronology that captured the essential elements of the case, including pre-op assessments, the procedure itself, post-op complications, and the corrective treatments provided after Rachel Doe’s bile duct injury was discovered. This chronology was then hotlinked to the Medical Management Record (MMR) for easy reference and access.  

However, we went beyond the basic services to provide a Medical Illustration , which significantly enhanced the case understanding.  

The Role of Medical Illustrations:  

To further clarify the complexities of the gallbladder surgery and bile duct injury, Trivent Legal provided a Medical Illustration as a value-added service. The illustration was developed after a thorough consultation with our senior MD, providing a visual, step-by-step narrative of the key medical concepts involved.  

• Normal Anatomy : The first illustration depicts the healthy anatomy of the gallbladder and surrounding structures, establishing a baseline for understanding the surgical area.  
• Standard of Care : The second illustration demonstrates the correct placement of staples, showing how the procedure should have been performed according to the accepted standard of care.  
• What Went Wrong : The third illustration clearly highlights the error—where the clip was incorrectly placed—resulting in the bile duct damage.  

These illustrations were not only visually detailed but also included expert commentary from our senior MD, providing insightful explanations of the clinical aspects of the case. These expert insights were placed directly within the visuals, adding depth and clarity for the legal team.  

Value to Legal Professionals:  

For attorneys dealing with complex medical cases, Trivent Legal’s Medical Illustration service offers immense value. In just minutes, our medical visuals translate intricate surgical details into an easily digestible format, empowering attorneys to quickly understand the events, identify the standard of care breaches, and articulate the case to clients, jurors, or opposing counsel.  

What sets Trivent Legal’s Medical Illustration apart is that it was specifically designed to make complex medical cases accessible—even to those without medical expertise. The combination of visual clarity and expert insights ensures that every stakeholder, from attorneys to jurors, can grasp what happened, when it happened, and why it constitutes a breach of the standard of care.  

Conclusion:  

For attorneys navigating complex medical malpractice cases, Trivent Legal’s Medical Chronology , Hotlinks , and Medical Illustration services offer powerful tools that streamline case analysis and improve case presentation. Our approach simplifies intricate medical details and transforms them into clear, persuasive narratives, ultimately strengthening your case and improving your chances of a successful outcome.  

FAQs  

• What is Trivent Legal’s Medical Illustration service?  

It is a visual representation of medical events, anatomy, and errors, designed to simplify complex medical concepts for legal cases.  

• How does Medical Illustration help attorneys?  

It translates intricate surgical details into clear visuals, making it easier to explain the case to clients, jurors, and opposing counsel.  

• What other services complement Medical Illustration?  

Trivent Legal provides Medical Chronologies and Hotlinks , which offer detailed timelines and seamless navigation of medical records.  

• Can Medical Illustrations highlight deviations from the standard of care?  

Yes, illustrations compare normal anatomy and proper procedures with what went wrong, clearly demonstrating breaches in care.  

• How do I get Trivent Legal’s Medical Illustration services for my case?  

Contact us to discuss your case needs and discover how we can enhance your legal strategy with tailored medical visuals.  

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