04/29/2026
A preventable tragedy, and a breakdown at every level of care.
We recently resolved a wrongful death case involving a patient with known asthma and active inhaler use who was prescribed propranolol, a non-selective beta blocker, for migraine prevention, despite clear contraindications and safer alternatives. The prescribing provider was employed by a federally governed healthcare facility under the Federal Tort Claims Act (FTCA).
When the prescription reached the pharmacy, the system generated a high-level drug interaction alert warning the medication could blunt the effect of the patient’s rescue inhaler and trigger bronchospasm. The dispensing pharmacist, also employed by the same FTCA-governed facility, cleared the prescription without documented intervention, prescriber contact, or meaningful counseling. This was the final safety checkpoint before the medication reached the patient.
Within days of beginning the medication, the patient suffered a catastrophic asthma attack. The rescue inhaler failed. Rapid respiratory collapse followed, requiring mechanical ventilation and ECMO. The patient ultimately died from severe hypoxic brain injury.
The matter was ultimately resolved for $1,000,000.00, with the focus remaining where it belongs, on accountability and patient safety.
This case highlights critical failures: prescribing a contraindicated medication in a high-risk patient, failing to reassess worsening respiratory status, and disregarding pharmacy safety alerts, the last line of defense.
When multiple safeguards are bypassed, the consequences are irreversible.
