Are you well positioned to resolve conflicts with the safety of an order? Learning from a physician’s homicide trial and the firing of multiple healthcare workers

A former Ohio physician accused of hastening the deaths of 14 patients by prescribing large doses of opioids for terminally ill patients was recently found “not guilty” of homicide.¹ The jury of 12 told the judge that they were at an “impasse” several days into the deliberation, but the judge instructed the jury to keep deliberating, and the jury reached a “not guilty” verdict 2 days later. While the opioids were administered to patients at the end of life after removal from a ventilator, the verdict was unexpected. Unusually large doses, such as 2,000 mcg of fentaNYL intravenously (IV), had been prescribed.² Sometimes the doses were repeated and administered along with a benzodiazepine and/or another opioid such as HYDROmorphone.³

Although the prescribing physician was acquitted of homicide, the State Medical Board of Ohio permanently revoked his medical license.⁴ Additionally, the event led to the firing of more than 20 pharmacists and nurses at the hospital, the referral of dozens of practitioners to state professional boards for possible disciplinary action (e.g., reprimands, suspensions or permanent revocation of their licenses), and numerous civil lawsuits against the hospital and the health system.^5-7 Fortunately, the prosecutor’s office stated that no nurse or pharmacist associated with this case would face criminal charges for their involvement in the patients’ deaths.¹

During testimony at the trial, it was clear that some practitioners who worked with this physician felt uncomfortable with the medication orders.² Still, for 4 years (2015-2018), the physician prescribed high opioid doses for numerous end-of-life patients, and various nurses administered these high doses after removing the medications from an automated dispensing cabinet (ADC), mostly via override before a pharmacist could verify the order. How did something like this occur and continue for 4 years? The following discussion explores that question and provides recommendations to help practitioners and health systems address concerns with the safety of an order when they arise. This includes the development of an established escalation process to promptly resolve these disputes.

Intimidated by the Prescriber’s Exceptional Reputation

Unfortunately, healthcare practitioners do not always bring their concerns about the safety of a medication order to the attention of the prescriber, particularly if the prescriber has an exceptional reputation.⁸ During the homicide trial, three witnesses spoke about the physician’s admirable reputation and how he had been a mentor to staff members, teaching them ways to improve patient care. One intensive care unit (ICU) nurse described him as, “Just a genuine guy when he was talking to family members and powers of attorney about how sick the patients were,” adding that, “I believe he cared for his patients deeply.”⁹ Nurses also testified that they had not received formal training about fentaNYL or opioid dosing and, thus, felt the need to trust the physician’s judgement.

In our 2021 survey about disrespectful behaviors, 33% of more than 1,000 practitioners had assumed a medication order was safe in the past year because of the stellar reputation of the prescriber, despite their concerns about the safety of the order.⁸ They assumed that the prescriber knew more than they did about an unfamiliar medication, or they feared falling out of favor with the prescriber if they questioned an order.¹⁰

Convinced the Dose Was Safe

Did practitioners question the high opioid doses prescribed by the former physician? Yes, it appears that a few practitioners had contacted the physician to express their concerns. During the homicide trial, one ICU nurse noted that a pharmacist had reviewed and rejected an order for 1,000 mcg of IV fentaNYL.⁹ Yet, the physician allegedly assured an ICU nurse on multiple occasions that “the order was good to go.” According to a news report, when the physician was questioned by nurses and pharmacists regarding the high-dose orders, he would offer a long explanation to justify the order, touting his residency work as an anesthesiologist at a prestigious academic medical center.²

This is a less obvious but no less dangerous risk related to the culture that often goes unnoticed until a serious adverse event happens: staff speak up about potential safety concerns, but they are easily convinced that their concerns are unfounded. Surprisingly, many harmful prescribing errors that reach patients share this common factor: at least one person—a healthcare practitioner, patient, or family member—felt there was a problem with the order before the medication was dispensed and/or administered.¹¹ When practitioners, patients, or family members voice a concern, an explanation from a practitioner may dispel the initial concern too quickly before it has been given sufficient consideration. A pharmacist reassures a technician that the compounding directions are correct when questioned about an unusual volume of ingredients; a pharmacist assures the nurse that the strength of the infusion is correct when questioned about the final volume; a nurse reassures a patient that the medication is correct when questioned about its appearance; a physician convinces a pharmacist that the prescribed dose is correct when questioned because it differs from a protocol—these are all-too-frequent examples that have led to fatal adverse drug events.¹¹

In our 2021 disrespectful behavior survey, nearly half (47%) of the respondents said they have felt pressured to accept an order, dispense a product, or administer a drug despite their concerns about its safety.⁸ Practitioners reported that they sometimes move forward despite a feeling that something is wrong because they are unable to express their concerns clearly, or the concern is not taken seriously by the prescriber. 

Defining a Process

At your practice site, do staff always feel comfortable reaching out to a prescriber to address concerns when a prescribed treatment varies from the expected standard of care, or when duplicate therapy is prescribed, or when a medication dose exceeds what is typically considered safe? Are you confident that the prescriber takes all expressed concerns about the safety of an order seriously? Furthermore, if a conflict in the safety of an order arises in which the prescriber does not take the expressed concern seriously, does your organization have a clear and well-known escalation process to promptly resolve the dispute? Although the process for handling drug therapy concerns objectively and professionally may vary to meet the unique needs of individual organizations, consider the guidelines below when developing or revising your process.

Conflict Resolution Guidelines

Gather information. If a nurse, pharmacist, or other healthcare professional suspects that an order is potentially incorrect based on either toxicity (e.g., overdose) or efficacy (e.g., wrong antibiotic), they should gather information to present to the prescriber when contacting them about their concern. A nurse may contact a pharmacist to help research the issue so factual information that supports the expressed concerns can be clearly communicated to the prescriber. The pharmacist or nurse might need to review the patient’s health record; talk with the patient; use reputable drug information resources; and consult other nurses, pharmacists, or physicians to gather the information needed to communicate the drug order concern effectively.

Question the order. Organizations should foster a culture of safety that enables pharmacists and nurses to not fear questioning an order when they have reason to believe a patient is at risk, or even if they just have a sense that something is wrong. To help overcome fear, practitioners can focus on which would be worse: to be wrong, or to allow an injury to a patient. Any questionable order should be discussed directly with the prescriber. The use of a standard communication strategy, such as SBAR or TeamSTEPPS, can help frame the discussion.

If applicable, the pharmacist or nurse should ask the prescriber for documentation (e.g., protocols, journal articles) supporting the order and read any materials provided. Statements such as “the protocol says to do it this way” or “that’s how they do it at another hospital” should never be accepted as proof and should signal the need for further investigation.¹¹ Check with risk management regarding the best way to document any safety concern and the prescriber’s response to the concern.

If the prescriber will not change the order and the practitioner is still not satisfied that the patient will not be harmed, the prescriber should not be asked, nor allowed, to personally administer the drug. Transferring responsibility to the prescriber for possible patient harm is not likely to absolve the questioning practitioner if patient harm occurs. Instead, escalate the concern on behalf of the patient.

Escalate the concern. A healthcare practitioner’s persistence in communicating recognized, or even vague, concerns about the safety of an order can clearly prevent harmful errors from reaching patients, even when the perceived problem is met with opposition from experts. Thus, an effective process for handling medication therapy conflicts requires more than a hierarchical structure of referring problems up the chain of command. Staff members also need clear guidance and support from organizational leaders to follow when those in authority, such as a prescriber, do not agree with their expressed concerns. Unfortunately, more than half (58%) of respondents to our 2021 disrespectful behavior survey said their organization’s process for handling clinical disagreements does NOT allow them to bypass a typical chain of command if necessary.⁸ Thirty-seven percent of respondents could not answer the survey question on this topic because they did not know if they could bypass the chain of command.

In cases involving conflict between a prescriber and a healthcare practitioner who clinically cannot determine how to proceed, there must be a formal process that allows clinical staff to bypass the chain of command up until the point where everyone feels that it is clinically appropriate to move forward. For example, the prescriber’s chief resident, attending physician, department chair, or a specialist in the area of the ordered drug therapy might be contacted. Escalation outside of a particular department may be needed, which might include contacting a hospital administrator or a defined senior leader to mediate the difference of opinion. Or an escalation team identified by senior leaders might be rapidly deployed for handling conflicting opinions objectively and professionally, beyond the walls of the patient room. Depending on the nature of the patient care disagreement, the escalation team could include the department chair or a practitioner with expertise in a subspecialty. The goal is to deploy a clinician or a team with knowledge about the issue, the skill to mediate, and the power to resolve the issue outside of the usual chain of command. Resolution of the issue needs to be accomplished in a timely fashion to ensure that the patient is cared for in the moment.

If the patient’s well-being is likely to be compromised while escalating the concern, and the patient’s clinical condition requires immediate attention, we have previously recommended calling a rapid response team.¹⁰ Rapid response teams are triggered by patient deterioration or a change in clinical status and are designed to respond accordingly to facilitate stabilization. However, a rapid response team should not be called to resolve treatment conflicts between healthcare practitioners, as the team likely will not include experts in the topic under question. If needed, a rapid response team should focus on patient care, and an escalation team should focus on resolving the conflict in a timely fashion.

Conclusion

We strongly encourage organizations to review this case at their medication safety committee meeting and to develop a process that swiftly and appropriately responds to conflicts about the safety or efficacy of an order. To promote the need to speak up and to persist with any concerns about the safety of an order, the conflict resolution process should be included in employee orientation and practiced in simulations to increase awareness and improve comfort levels.

The hospital where this event happened has established a new escalation policy for orders that are concerning or represent deviations in established protocols. The hospital also limited the amount of specific medications available for emergency override through an ADC, set maximum dosages for pain medications in the electronic health record, increased education on end-of-life care, and now more closely monitors the appropriateness of ADC overrides.² If your hospital has not already done so, consider taking these steps, as well.

References

1. Bruner B. William Husel verdict: five things we know. The Columbus Dispatch. April 20, 2022.  
2. Viviano J, Sullivan L, Wagner M. Doctor skirted pharmacists, nurses. The Columbus Dispatch. February 8, 2019.
3. Timeline of the William Husel case. The Columbus Dispatch. June 5, 2019.
4. Behrens C. State medical board approves permanent revocation of William Husel’s medical license. The Columbus Dispatch. May 12, 2022.
5. NBC4 staff. Names released of 25 nurses under review in connection to Husel investigation. NBC4i.com. March 14, 2019. Updated July 11, 2019.   
6. Ghose C. Mount Carmel, pharmacists reach settlement with state regulators in Husel case. Columbus Business First. March 4, 2020.  
7. Romine T. Colleagues of doctor accused of killing patients by overprescribing pain medication sue hospital. CNN. December 20, 2019.
8. ISMP. Survey suggests disrespectful behaviors persist in healthcare: practitioners speak up (yet again) – part I. ISMP Medication Safety Alert! Acute Care. 2022;27(4):1-5.  
9. Walsh M. Family members, ICU nurses paint different pictures of Husel in trial’s fourth week. NBC4i.com. March 18, 2022.   
10. ISMP. Resolving human conflicts when questions about the safety of medical orders arise. ISMP Medication Safety Alert! Acute Care. 2008;13(5):1-2. 
11. ISMP. Raising the index of suspicion: red flags that represent credible threats to patient safety. ISMP Medication Safety Alert! Acute Care. 2012;17(15):1-3.