Malpractice Case Study: Insufficient Monitoring of Narcotic Medications

In a 2025 study of ambulatory medicine–related malpractice claims, narcotics accounted for 15.6 percent of claims and the leading contributing factors included clinical judgment (55 percent) and communication issues (48 percent). This case study illustrates the risks associated with polypharmacy and patient nonadherence with opioids.

Allegation

The patient’s spouse alleged negligent prescribing of opioid medications by the original family practice physician, causing addiction that led to the patient’s death.

Background

A middle-aged patient was discharged from the hospital after a short stay for COPD management. The patient had a decades-long history of anxiety and chronic pain. The patient was returned to the care of the family medicine physician who had followed the patient for chronic pain for over 22 years. Discharge medications included oxycodone 15 mg 4 times a day and diazepam 5 mg 2 times a day. The family medicine physician prescribed oxycodone 30 mg every 4 hours with 120 tablets of oxycodone 15 mg for breakthrough pain and diazepam 5 mg 2 times a day. Less than 2 weeks later, the family medicine physician refilled the patient’s prescriptions due to patient complaints of ongoing chronic pain. 

The patient’s spouse arrived at the family medicine physician’s office 3 weeks later with the patient unresponsive in the back seat of the car. The spouse commented that the patient over-medicated between 4 and 5 days per week. The physician called for an ambulance. Upon arriving at the ED, the patient was admitted for respiratory depression. The hospitalist discharged the patient 4 days later with medications that included diazepam 2.5 mg 2 times a day and oxycodone 15 mg every 6 hours as needed for severe pain. The hospitalist advised the patient to maintain the discharge doses and to follow up with the family medicine physician. The hospitalist documented that the patient should be prescribed limited amounts of oxycodone to prevent a recurrence.

The patient returned to the family medicine physician, who renewed the prescriptions without changes. However, the physician and his drug abuse counselor met with the patient, who agreed to the spouse being present when the medications were dispensed. The terms and agreement were documented in a pain contract signed by the patient and spouse. The patient did not comply with the terms of the pain contract and was eventually dismissed from the practice.

The patient found a new primary care physician, who prescribed clonazepam, hydrocodone, COPD medications, and antidepressants. Four years after changing family physicians, the patient was found cold and unresponsive at home and pronounced dead. 

The case went to trial and resulted in a verdict for the defense.

Patient Safety Considerations

Although the verdict favored the family medicine physician, and the defense witnesses agreed the physician met the standard of care for opioid management at the time the care was given, there are learning opportunities present in this case.

Communication

• The family medicine physician refilled the prescriptions early without seeing the patient, thus missing an opportunity to look for new signs and symptoms, review the pain contract, and discuss the risks of nonadherence to the treatment plan.
• The patient’s spouse was aware the patient was deviating from the treatment plan but did not report it in a timely manner.
• The hospitalist did not call the family medicine physician to discuss opioid dosing before discharging the patient. It is not clear whether the physician was aware of the hospitalist’s recommendation.

Chronic Pain Management

• Use evidence-based pain management guidelines, such as the American Academy of Family Physicians Chronic Pain Toolkit and the CDC Clinical Guidelines for Prescribing Opioids for Pain.

Managing Patient Nonadherence

• Identify and address barriers to patient adherence.
• Use care when dismissing patients from your practice.

This case demonstrates the positive effects that following the existing standard of care and appropriately managing nonadherent patients may have on the outcome of a malpractice claim.

For assistance, contact Patient Safety and Risk Management at (800) 421-2368 or patientsafety@thedoctors.com.