On November 7, 2022, the Inside Medical Malpractice podcast released an extended conversation between host Chris Rokosh and Paul on medication errors. The episode runs 1 hour and 20 minutes and is the second in a five-part series the podcast was producing on top issues in medical malpractice. The five topics in the series are Assessment, Medication Errors, Communication, Infection Control, and Unsafe Use of Equipment. Paul, who first appeared on Inside Medical Malpractice in June 2020, returned as a repeat guest to take the Medication Errors instalment.
The Never Events framework
The episode’s substantive framework is the concept of the Never Event in patient safety. Never Events are defined, in the joint 2015 report of Health Quality Ontario and the Canadian Patient Safety Institute, Never Events for Hospital Care in Canada, as patient safety incidents that result in serious patient harm or death and that are preventable using organizational checks and balances. The HQO/CPSI report identifies 15 Never Events. As the episode notes, three of those 15 are medication-related, reflecting how widespread medication error continues to be as a source of preventable serious harm.
The Never Events framework is not itself a doctrinal legal concept. It is a patient safety construct that hospitals and health systems use to organize their internal quality-improvement work. The legal relevance is indirect but real. When a Never Event occurs and litigation follows, the plaintiff’s case is often supported by the existence of widely-recognized, system-level frameworks for preventing the very event that occurred. The defendant institution can be asked, in plain terms, why the framework was not followed. Paul has worked with the Never Events concept across several settings (his May 2026 OTLA Spring Conference paper on surgical Never Events is the most developed treatment in the project), and the November 2022 podcast is an earlier conversational treatment focused on the medication subset.
The 10 rights of medication administration
The episode is organized around the framework that nursing and pharmacy education has used for decades to teach safe medication administration: the so-called rights of medication administration. The traditional five rights (right patient, right drug, right dose, right route, right time) have been expanded over the years to as many as ten in different formulations, with additions like right documentation, right reason, right response, and right to refuse.
The rights are basic. They are taught early in healthcare education and reinforced throughout clinical training. The episode’s argument, which Paul develops through cases from his own practice, is that the rights are not the problem. The rights are well-understood. The problem is the systemic and individual failures to apply them at the point of care, particularly when fatigue, time pressure, distraction, or assumptions about prior verification compromise the discipline.
Where the cases come from
The episode describes Paul presenting several cases from his own practice involving nurses, doctors, and pharmacists who gave the wrong drug, or the wrong dose, at the wrong time, without appropriate follow-up. The specific cases are not identified by name in the publicly available material, and the conversation is the best place to hear Paul’s own treatment of them.
The structural point that comes through in any working description of this litigation is that medication-error cases often involve multiple defendants across multiple roles. A medication error in a hospital setting may implicate the prescribing physician (the wrong drug or dose was ordered), the dispensing pharmacist (the order should have been flagged), the administering nurse (the dose should have been checked), and the institution itself (the system that allowed all of those checks to fail). The legal architecture for assigning liability across that web is non-trivial. The standard of care analysis has to be done role-by-role, and the causation analysis has to address how the chain of decisions ultimately produced the harm. Documentation is central, both because the medication administration record is often the contemporaneous account of who did what and when, and because gaps in the record are themselves evidentiary.
The advice the episode offers
The episode is pitched simultaneously at three audiences: healthcare providers, the public, and lawyers who litigate these cases. For the first, the advice is practical: do not skip the rights. For the second, the advice is to be informed and to ask questions. For the third, the episode offers Paul’s working perspective on how to build a medication-error case.
The host’s framing of the takeaway, as the episode description puts it, is to never, ever get complacent. The framing applies across all three audiences. Complacency, in this context, is the same thing in the hospital and in the courtroom: the assumption that the checks have been done because the checks are always done. Medication-error litigation is, in many cases, the legal consequence of someone in the chain having assumed that someone else verified what they themselves did not verify.
Where to listen
The full episode is available on Spotify at open.spotify.com. More information about the Inside Medical Malpractice podcast and the work of Connect MLX is available at connectmlx.com.
Context
At the time of the November 2022 episode, Paul was a partner at Will Davidson LLP. The firm restructured later, and Paul is now a partner at Davidson Cahill Morrison LLP. Medication errors continue to be a meaningful component of Paul’s practice; the Medication Errors practice page on paulcahill.ca sets out the case categories and contact information.
This is Paul’s second appearance on Inside Medical Malpractice. The first was the three-episode trial series with Chris Rokosh in June 2020, covering Hacopian, O’Neill-Renouf, and Woods v Jackiewicz.
