Malpractice Case Study: Negligent Opioid Prescribing

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 rapidly increasing the dosage of long-acting opioids.

Allegation

The family alleged negligent opioid prescribing, resulting in overdose and death.

Background

An adult with a history of chronic low back pain, lower extremity pain, depression, and anxiety established care with a family medicine physician and their advanced practice clinician. The patient’s medications included celecoxib, sertraline, and Percocet as needed for pain. During a follow-up visit for low back pain, the physician increased the Percocet to 1 tablet 1 to 2 times daily, and 30 tablets were prescribed with no refills. The patient agreed to participate in physical therapy.

The patient was seen 2 weeks later for back pain radiating from the right leg into the foot, described as 15 on a scale of 1 to 10. The patient stated that the Percocet was not working. The physician’s review of systems noted frequent urination, nocturia, difficulty starting and stopping stream, and incontinence. Orders included an electromyogram and OxyContin 15 mg 1 tablet 3 times daily (67.5 MME/day), and 90 tablets were prescribed with no refills. The patient was scheduled for follow up in 2 weeks.

The patient called 2 days later to request an appointment that day due to increased back pain the preceding night continuing into the morning. The physician increased the prescription for OxyContin to 2 pills 3 times daily and told the patient to call the office in a few days. The patient was found unresponsive the next morning and pronounced dead.

Key Contributing Factors in the Claim

Inadequate Communication

• The physician did not educate the patient on how to properly take the medication and the risks involved if not taken properly.
• The physician did not develop a collaborative treatment plan with the patient, including goals and expectations.

Inappropriate Medication Management

• The physician did not follow evidence-based opioid pain management guidelines.
• The physician did not perform a comprehensive pain management history and physical.
• The physician did not allow time to assess the effect of non-pharmacologic pain management strategies (physical therapy).
• The physician did not offer naloxone when switching from a short-acting opioid to a long-acting opioid.

Patient Safety Considerations

• Actively manage patients taking opioids. Opioids have significant potential for severe adverse effects and patient harm and are considered high-alert medications that must be managed carefully using evidence-based guidelines. Use guidelines such as the American Academy of Family Physicians Chronic Pain Toolkit and the CDC Clinical Guidelines for Prescribing Opioids for Pain.
• Consider that community pharmacists may be an untapped resource, and ensure you respond to their questions and recommendations.
• Use the prescription drug monitoring program in the state(s) you prescribe in.

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