Flanagan’s Propofol Case
Ruth Ann Terry v. Amy Brunner
The court document can be found here.
Case Background:
On 6/6/2003, Amy Brunner, R.N., was scheduled to work a 12 hour shift (19:00 to 7:00) in the ICU at Providence Saint Joseph’s Medical Center in Burbank, California. At 1:00 a.m. on 6/7/03, Brunner was asked by co-worker Kelly Ann Miyasato, R.N., if there was a drug available for agitation that could be given to one of her patients. Brunner identified two patients who were currently receiving Diprivan, and withdrew 4-5 ccs of the drug from the IV of one of those patients. Brunner left the syringe for Miyasato to administer to her patient through an IV push.
There was no doctor’s order for Diprivan for Miyasato’s patient, and the patient was not intubated or ventilated either before or after receiving it. At about 2:05 a.m. the drug was administered; immediately afterward the patient’s oxygen saturation and heart rate began to deteriorate. Brunner attempted to help Miyasato reverse the effects of the Diprivan through oxygen, an Epinephrine IV, and a Narcan IV.
The patient was pronounced dead at 2:15 a.m., 6/7/03.
The Charges:
Count 1: Gross Negligence
- “Respondent performed duties outside the scope of the nursing practice and hospital policy by voluntarily withdrawing 4 to 5 ccs* of Diprivan from one patient’s IV and allowing it to be administered IVP to R.N. Miyasato’s patient. Diprivan IVP can only be administered to an intubated or ventilated patient, by a physician or an anesthesiologist.
- Respondent failed to obtain and verify the physician’s order for Diprivan for patient.
- Respondent obtained Diprivan to be administered IVP to a patient who was neither intubated nor mechanically ventilated.
- Respondent failed to follow professional and regulatory standards within the scope of medication delivery. Respondent failed to institute appropriate reversal drugs and emergency procedures. Respondent failed to recognize that Diprivan is not a narcotic and that Narcan would not be effective in reversing Diprivan’s effects.
- Respondent failed to adhere to standard infection control guidelines and regulations when Respondent withdrew Diprivan from one patient’s IV medication to be injected directly into another patient’s bloodstream through an IV cannula thereby risking transmission of blood-borne infectious diseases from patient to patient and from patient to nurse.”
Count 2: Incompetence
Count 3: Unprofessional Conduct
Count 4: Failure to Follow Infection Control Guidelines
Count 5: Violation of the Nursing Practice Act
* 4 ccs IVP would be equivalent to 40 mg. of Diprivan, which is the general anesthesia induction dose.
This case was brought by Ruth Ann Terry, Executive Director of the Board of Nursing and was filed before the Board of Registered Nursing, Department of Consumer Affairs. Terry was represented by Bill Lockyer, Attorney General of the State of California.
The criminal trial was held separately. Read about it here.
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