Letter to the Editor

        Medication Errors and Homicide

        Alan Horowitz eloquently describes how a nurse was scapegoated for the failings of a faulty system in his recent article “Medication Errors and Homicide: When Law and Medicine Collide” (Caring for the Ages, 23(5)). The one part of the system omitted from this analysis was the original order for midazolam (“Versed”). AMDA members are well-aware of the risks of such a medication, especially in older adults with dementia.
        The FDA mandated midazolam package insert states, “Intravenous midazolam has been associated with respiratory depression and respiratory arrest, especially when used for sedation in noncritical care settings. In some cases, where this was not recognized promptly and treated effectively, death or hypoxic encephalopathy has resulted. Intravenous midazolam should be used only in hospital or ambulatory care settings, including physicians’ and dental offices, that provide for continuous monitoring of respiratory and cardiac function, i.e., pulse oximetry” (available at:
        Press accounts of this case raise questions about the judgment that led to the midazolam order. Was there a change in the neurologic exam indicating that a second brain imaging study may have demonstrated a new brain lesion? Was the possible benefit of the scan worth the risk of midazolam? Would midazolam properly be viewed as a chemical restraint to allow the performance of a test? Was appropriate monitoring equipment present in the radiology suite?
        Rather than highlighting the error of one nurse, this case highlights the geriatric medicine principle that often, less is more. This case also highlights the power differential between the doctor and the nurse.
        Eric Reines, MD, FACP
        Marblehead, MA
        Alan Horowitz, Esq., RN, extends his thanks for this letter and appreciates that Dr. Reines underscores the systems nature of medication errors.