Title: Klasch v. Walgreen Co.

State: nevada

Issuer: Nevada Supreme Court

Document:

om

427 Nev,, Advance Opinion “74F
IN THE SUPREME COURT OF THE STATE OF NEVADA

DENNIS KLASCH, INDIVIDUALLY; No. 64805
MARILYN LIND, INDIVIDUALLY; AND

DENNIS KLASCH, MARILYN LIND,

AND REVAS. ARCHER, AS CO-

SPECIAL ADMINISTRATORS FOR FILED
‘THE ESTATE OF HELEN KLASCH,

Appellants, Nov 23 201
WALGREEN CO., AN ILLINOIS custo pi er
CORPORATION D/B/A WALGREENS, ”. a
Respondent.

 

Appeal from a district court summary judgment in a wrongful
death action. Eighth Judicial District Court, Clark County; Michelle
Leavitt, Judge.

Reversed and remanded,

Bradley Drendel & Jeanney and Bill Bradley, Reno,
for Appellants.

Stutz, Artiano, Shinoff & Holtz and James F. Holtz, Las Vegas,
for Respondent.

BEFORE THE COURT EN BANC.

OPINION

By the Court, PARRAGUIRRE, J.:
In this appeal, we consider the duty of care that a pharmacist

owes his or her customers. Specifically, we are asked to clarify whether a

 

 
pharmacist’s only duty is to fill a customer's prescription with the correct
medication and dosage or if, under certain circumstances, a pharmacist
may have a duty to do more. We conclude that when a pharmacist has
knowledge of a customer-specific risk with respect to a prescribed
medication, the pharmacist has a duty to exercise reasonable care in
warning the customer or notifying the prescribing doctor of this risk.
Having determined that the pharmacist in this case had knowledge of a
customer-specific risk, we conclude that the summary judgment record
before the district court was inadequate to conclude, as a matter of law,
that no genuine issues of fact remain as to breach of duty and causation of
injury. Accordingly, we reverse the district court’s summary judgment in
favor of respondent and remand this case to the district court.
FACTS

In December 2005, Helen Klasch visited Dr. Fredrick
Tanenggee, M-D., for the first time, While filling out paperwork
concerning her medical history, Klasch indicated that she might have a
sulfa allergy. People with sulfa allergies generally experience minor skin
rashes when exposed to sulfa, but in a small number of cases, the sulfa
exposure may cause a toxic reaction in the person's skin, potentially
leading to death.’ Although still largely unpredictable, people who have
experienced a past allergic reaction to sulfa are at a heightened risk for

1As explained by appellants’ proffered standard-of-care expert, this
reaction is known as Stevens-Johnson Syndrome or Toxic Epidermal
Necrosis (SJS/TEN). A person afilicted with SJS/TEN may suffer
“blistering of the mucous membranes, typically in the mouth, eyes, and
vagina, and patchy areas of rash, followed by the entire top layer of skin
(the epidermis) peeling off in sheets from large areas of the body.”

 

 

 
suffering this toxic reaction in the event of future sulfa exposure. After
some further discussion with Dr. Tanenggee’s assistant, this possible sulfa
allergy was recorded on Klasch’s medical chart with a question mark
(Sulfa?)

In July 2006, Klasch returned to Dr. Tanenggec's office,

complaining of “abdominal fullness.” After performing routine tests, Dr.

 

‘Tanenggee diagnosed her with a urinary tract infection. Dr. Tanenggee
told Klasch that under normal circumstances, her infection could be

treated most effectively with Bactrim, a sulfa-based antibiotic, Given the

  

notation in her chart, however, Dr. Tanenggee asked Klasch to clarify how
certain she was of her sulfa allergy. After some further discussion, Klasch
downplayed the previous notation and asked Dr. Tanenggee to write her a
prescription for Bactrim. Dr. Tanenggee complied, and Klasch dropped off
the prescription at Walgreens Pharmacy on her way home from Dr.
Tanenggee’s office.

Later that same day, Klasch’s caretaker returned to
Walgreens to pick up the prescription. Upon asking a pharmacy employee
to release the prescription, the employee told the caretaker that Klasch’s
prescription had been “flagged” by Walgreens’ computer system while it
was being filled. Walgreens maintains a “patient profile” for each of its
customers, which its pharmacists use to identify any potential allergic
reactions, harmful interactions with other medications, or adverse side
effects that a customer may have to a particular medication. ‘The
employee told Klasch’s caretaker that the prescription had been flagged

because Klasch’s patient profile indicated that she was allergic to sulfa-

 

 
based drugs.? ‘The caretaker then asked the employee to call Klasch and
to speak with her directly.

A Walgreens employee called Klasch and conveyed that her
prescription had been flagged because of her sulfa allergy. In response,
Klasch reportedly indicated that she had taken Bactrim in the past and
that she had not experienced any adverse reaction to it. Satisfied with
this clarification, a pharmacist then manually overrode the computer

system's flag, and the prescription was released to Klasch’s caretaker.

 

Later that day, after taking the medication, Klasch
complained that sho folt “itchy.” The following day, Klasch called Dr.
‘Tanenggee’s office and left a voice mail in which she stated that she was

 

wrong about not having a sulfa allergy. Klasch’s condition continued to
worsen, and she was taken to the emergency room. After being diagnosed
with SJS/TEN, Klasch was transferred to a burn center, where she
eventually lapsed into a coma and passed away. At the time Klasch was
removed from life support, she had burns covering 40 to 50 percent of her
body.

“The record is not clear as to when or why Walgreens entered
Klasch’s sulfa allergy into her patient profile. It does show that, in 2000,
Walgreens filled a prescription for Klasch for a non-sulfa-based alternative
drug.

 

8The parties dispute the specifics of the encounter between Klasch’s
caretaker and Walgreens’ employee. In the caretaker’s deposition, she
gave the above account, and she was certain that the employee with whom
she spoke and who called Klasch was a man. Walgreens, however, asserts
that the person who spoke with the caretaker and who called Klasch was
the actual pharmacist, who was a woman. In her deposition, the
pharmacist recalled personally speaking with the caretaker to explain why
the prescription had been flagged and personally calling Klasch.

 

 
Klasch’s two children (the Klasches) brought a wrongful-death
action against Walgreens, alleging that its pharmacist breached the duty
of care owed to their mother. Specifically, the Klasches contended that
Walgreens’ pharmacist breached her duty of care by failing to adequately
warn Klasch of the prescribed medication’s risks in light of her allergy to
it or, alternatively, by failing to call Dr, Tanenggee to clarify whether he
really meant to prescribe a medication to which she was allergic.4

Walgreens filed a motion for summary judgment, contending
that in a majority of jurisdictions, the learned-intermediary doctrine limits
a pharmacist’s duty to do anything more than correctly fill prescriptions as
written. Walgreens contended that since its pharmacist had filled
Klasch’s prescription with the correct medication and dosage, it had, as a
matter of law, fulfilled its duty to her.®

Following what it perceived to be the “majority rule,” the
district court granted Walgreens’ summary judgment motion on the basis
that “the pharmacist’s limited duty is to properly fill the prescription, as
written by the physician, unless there is plain error or the prescription is
obviously fatal.” This appeal followed.

DISCUSSION

Although this court has not previously considered the learned-

intermediary doctrine, the issues raised in this appeal compel us to

“The Klasches also brought suit against Dr. Tanenggee, but the
parties reached a settlement prior to this appeal.

®Walgreens was also granted summary judgment on the Klasches’
negligent-infliction-of-emotional-distress claims, a ruling they do not
challenge on appeal.

 

 
consider its applicability and scope. In 80 doing, we first adopt the
Iearned-intermediary doctrine in the context of pharmacist/customer tort
litigation and hold that pharmacists have no duty to warn of a prescribed
medication’s generalized risks.

We next consider whether the learned-intermediary doctrine
likewise insulates a pharmacist from liability when he or she has
knowledge of a customer-specific risk, Following the modern trend of case
law, we conclude that the learned-intermediary doctrine does not foreclose
a pharmacist’s potential for liability when the pharmacist has knowledge
of a customer-specific risk. Instead, under these circumstances, a
pharmacist has a duty to exercise reasonable care in warning the
customer or notifying the prescribing doctor of the risk, Because factual

 

‘sues remain in this case regarding breach of duty and causation of
injury, we reverse the district court's summary judgment in favor of
Walgreens and remand this ease to the district court.6

‘Standard of review
We review an appeal from an order granting summary
judgment de novo. Wood v, Safeway, Inc., 121 Nev. 724, 729, 121 P.3d

1026, 1029 (2005). Summary judgment is appropriate “when the
pleadings and other evidence on file demonstrate that no genuine issue as
to any material fact remains and that the moving party is entitled to a

“Because neither party has addressed whether the statutes and
regulations governing the practice of pharmacy apply to this case, we do
not address any potential applicability in this opinion. See Edwards v.
Emperor's Garden Rest,, 122 Nev. 317, 330 n.38, 130 P.3d 1280, 1288 n.38
(2006) (noting that it is a party's responsibility to “present relevant
authority” in support of any arguments raised on appeal).

 

 
judgment as a matter of law.” Id. (quotation omitted). When reviewing a
motion for summary judgment, “the evidence, and any reasonable
inferences drawn from it, must be viewed in a light most favorable to the
nonmoving party.” Id.
‘The learned-intermediary doctrine prevents pharmacists from interfering
with the doctor-patient relationship

To prevail on a negligence claim, a plaintiff must establish
four elements: (1) the existence of a duty of care, (2) breach of that duty,
(3) legal causation, and (4) damages. Sanchez v, Wal-Mart Stores, 125
Nev. __, __, 221 P.3d 1276, 1280 (2009). At issue in this case is the
interplay between the first two elements: the scope of Walgreens’ duty,
and whether it may have breached this duty. Walgreens acknowledges
that it owed the Klasches’ mother a duty to correctly fill her prescription,
but contends that it did not owe her a duty to warn her of the risk the
medication posed to her or to notify her prescribing doctor of that risk.
Walgreens contends that these additional duties would be foreclosed
under the learned-intermediary doctrine.

‘Traditionally, the learned-intermediary doctrine has been used
to insulate drug manufacturers from liability in products-liability
lawsuits.” Under the learned-intermediary doctrine, a drug manufacturer

‘The learned intermediary doctrine derives from § 402A of the
Restatement (Second) of Torts.” Thom v. Bristol-Myers Squibb Co,, 353
F.3d 848, 851 (10th Cir. 2003). Section 402A of the Restatement (Second)
of Torts addresses a seller's liability for physical harm caused to a
consumer by the seller's product. Restatement (Second) of Torts § 402A
(1965). Comment k to section 402A explains that sellers of “[ujnavoidably
unsafe products,” such as prescription drugs, can avoid liability by

continued on next page...

 

 
is immune from liability to a patient taking the manufacturer's drug so
Jong as the manufacturer has provided the patient's doctor with all
relevant safety information for that drug.* It is then up to the patient's
doctor—who has the benefit of knowing the patient's specific situation—to
convey to the patient any information that the doctor deems relevant.
Jurisdictions adopting the learned-intermediary doctrine in
the context of pharmacist/customer tort litigation have put forth a similar
rationale: that between the doctor and the pharmacist, the doctor is in the
best position to warn the customer of a given medication’s generalized

risks.!° Or, viewed more pragmatically, the doctrine prevents pharmacists

= continued

including adequate warnings with the products in lieu of redesigning them
to make them safer. Id. § 402A emt. k.

"See Thom, 353 F.3d at 851 (‘[T]he ‘learned intermediary
doctrine’... shields manufacturers of prescription drugs from liability
where the manufacturer adequately warns a patient's prescribing
physician of the potential risks inherent in the use of the product.”),

*See McKee _v, American Home Products, Corp,, 782 P.2d 1045,
1050-51 (Wash. 1989) (“It is the physician who is in the best position to
decide when to use and how and when to inform his patient regarding
risks and benefits pertaining to drug therapy.” (quoting W. Page Keeton

et al., Prosser and Keeton on the Law of Torts § 96, at 688 (5th ed. 1984))).

"See, e.g., Eldridge v. Eli Lilly & Co., 485 N.E.24 651, 553 (IIL. App.
Ct. 1985) (‘The doctor acts as a learned intermediary on behalf of the
ultimate consumer. ... To fulfill] the duty which the plaintiff urges us to
impose would require the pharmacist to learn the customer's condition
and monitor his drug usage.”); Nichols v. Central Merchandise, Inc., 817
P.2d 1131, 1133 (Kan, Ct. App. 1991) ([BJecause the doctor is the learned
intermediary between the manufacturer and the patient, the patient
should rely on the doctor; the pharmacist, at least under the facts of this

continued on next page .

 

 
on

 

from constantly second-guessing a prescribing doctor's judgment simply in
order to avoid his or her own liability to the customer." In this sense, the
learned-intermediary doctrine preserves the pharmacist’ role as a conduit
for dispensing much-needed prescription medications,

Because we beliove that these public-policy considerations are

sound, we adopt the learned-intermediary doctrine in the context of

 

pharmacisticustomer tort litigation, Accordingly, Nevada pharmacists
have no duty to warn their customers of the generalized risks inherent in

the prescriptions they fil.

continued

case, has no legal duty to warn the patient of potential consequences from
the use of the drug prescribed by the doctor.”); Bichler v. Willing, 397
N.Y.S.2d 67, 59 (App. Div. 1977) ({Wyhen a consumer asks a druggist to
fill a prescription, thus enabling him to obtain a drug which is not
otherwise available to the public, he does not rely on the druggist’s
judgment[,] ... but rather he places that confidence and reliance in the
physician who prescribed the remedy.”).

"See, e.g, Ingram_y. Hook’s Drugs, Inc, 476 N.E.2d 881, 886-87
(Ind. Ct. App. 1985) (‘[WJeighing the benefits of a medication against,
potential dangers that are associated with it requires an individualized
medical judgment. This individualized treatment is available in the
context of a physician-patient relationship. . .. It is not present, however,
in the context of a pharmacist filling a prescription for a retail customer.”);
McKee, 782 P.2d at 1053 (‘Imposing a duty such as [the plaintiff] urges
would, in essence, require the pharmacist to question the physician's
judgment regarding the appropriateness of each customer's prescription.
Sound policy reasons exist for not imposing such a duty.”).

 

 
 

=

Jearned-i t_foreclose_a a
potential for liability when the pharmacist has knowledge of a customer-
specific risk

Having adopted the learned-intermediary doctrine, we next
define its scope. To this end, we find the Supreme Court of Illinois!
decision in Happel v, Wal-Mart Stores, Inc., 766 N.E.2d 1118 (2002), to be
particularly instructive. In Happel, a customer with an aspirin allergy
requested that Wal-Mart fill her prescription for Toradol, a drug that,
‘unbeknownst to the customer, was contraindicated for people with aspirin
allergies. Jd. at 1121. The customer had previously told Wal-Mart's
pharmacists that she was allergic to aspirin, and the pharmacists had
entered this information into the pharmacy’s computer system. Id.
Nonetheless, the pharmacist who filled the Toradol prescription released
it to the customer's husband without warning him of the contraindication.
dd.

After taking the medication and suffering injuries, the
customer brought a negligence action against Wal-Mart, contending that
its pharmacist had breached her duty of care by failing to warn the
customer's husband that the Toradol prescription was contraindicated for
people with aspirin allergies. Id. at 1122. ‘The trial court granted Wal-
Mart’s summary judgment motion on the basis that Wal-Mart had no duty
to warn of the drug's risks. Id.

1A contraindication is a serious limitation on a drug's use,
necessarily implying grave consequences if it is ignored.” Happel, 766
N.E.2d at 1125; see Hand v. Krakowski, 453 N.Y.S.2d 121, 123 (App. Div.
1982) (a contraindication refers to “a circumstance under which the drug
must never be given” (quotation omitted).

 

10

 
 

On appeal to the Supreme Court of Ilinois, Wal-Mart
contended that the learned-intermediary doctrine foreclosed any duty to
warn the customer of the drug’s risks and that the trial court had
therefore properly granted it summary judgment. [d, at 1125, The
Happel court rejected this argument, concluding that “this case is outside
.” Id. at 1127.

In reaching this conclusion, the Happel court first explained

the purview of the learned intermediary doctrin

 

that the purpose behind the doctrine was to prevent a pharmacist from
interjecting himself into the doctor-patient relationship, which would, in
essence, force the pharmacist to “practice medicine without a license.” Id,
(quotation omitted). In spite of this general rule, however, the court went
‘on to conclude that “[tJhese reasons for not imposing a duty to warn on
pharmacists do not apply in the instant case.” Id, Specifically, the court
pointed to the fact that Wal-Mart “was aware not only of [the customer's]
drug allergies, but also that Toradol was contraindicated for
Id, Given these facts, the Happel
court concluded that “[iJmposing a duty to warn of this contraindication

 

persons... . with allergies to aspirin,

would not require the pharmacist to learn the customer's condition and
‘monitor his drug usage,” nor would it force the pharmacist to “practice
medicine without a license.” Id, at 1128 (quotations omitted).

Having concluded that the public-policy considerations behind
the learned-intermediary doctrine are less persuasive when a pharmacist
has knowledge of a customer-specific risk with respect to a prescribed
medication, the Happel court concluded that Wal-Mart indeed owed its
customer a duty, In remanding the case to the trial court, the Happel
court framed Wal-Mart's duty as follows:

[Wle hold that narrow duty to warn exists where, as in
the instant case, a pharmacy has patient-specific information

uw

 
os

 

 

about drug allergies, that the drug being prescribed
is contraindicated for the individual patient. In such
instances, a pharmacy has a duty to warn either the
prescribing physician or the patient of the potential danger.

Id. at 1129. See Walton v. Bayer Corp., 643 F.3d 994, 1000 (7th Cir. 2011)
(What a pharmacy sometimes knows, however, —_ without

investigation, ...and even a treating physician may not know, is

 

susceptibilities of particular customers of the pharmacy to the side effects
of a drug that it sells them—susceptibilities because of other drugs that
the pharmacy knows the customer is taking, or a pre-existing physical or
mental condition (again known to it) that makes the drug contraindicated
for the customer—and then it must warn either the customer or his
physician, But not otherwise.” (citations omitted)).

We find the analysis of the Happel court persuasive.

Consistent with the Supreme Court of Illinois and what we perceive to be

 

the modern trend of case law, we hold that the learned-intermediary

doctrine does not insulate a pharmacist from liability when he or she has

 

knowledge of a customer-specific risk." Instead, when a pharmacist ha:

 

“Consistent with Happel, numerous other jurisdictions have
trended toward imposing a limited duty on pharmacists so as to account
for situations in which a pharmacist has knowledge of a customer-specifie
risk. Compare Schaerer v. Stewart's Plaza Pharmacy, Inc,, 79 P.3d 922,
933 (Utah 2003) (‘We extend the learned intermediary rule to exempt
pharmacies from strict products liability when they properly fill a
physician's prescription.”), with Downing v. Hyland Pharmacy, 194 P.3d
944, 948 (Utah 2008) ("{O]ur application of the (learned-intermediary] rule
in Schaerer does not mean that we will not limit its application to
negligence claims when the facts and public policy require such limitation.
We conclude that this is such a case. ‘The facts alleged here state a cause
continued on next page . .

12

 
such knowledge, the pharmacist has a duty to warn the customer or to
notify the prescribing doctor of the customer-specific risk.
Factual issues remain

Having adopted the learned-intermediary doctrine and defined
its scope, we consider its application to the facts of this case. Here, the
Klasches contend that Walgreens’ pharmacist breached her duty of care by
failing to adequately convey the potential danger inherent in a person
with a sulfa allergy taking a sulfa-based medication, Because a sulfa
allergy is not the type of generalized risk for which the learned-
intermediary doctrine insulates a pharmacist from liability, and because
Walgreens arguably had specific information at its disposal regarding
Klasch’s sulfa allergy, the learned-intermediary doctrine does not insulate
Walgreens from liability as a matter of law.

Walgreens contends, however, that it discharged its duty
when one of its employees phoned Klasch and relayed the contents of its
computer system to her. Walgreens further argues that, even
duty and breach, it did not cause Klase

 

suming

 

jury because her prescribing
doctor knew she might have a sulfa allergy yet prescribed Bactrim
anyway.

‘The difficulty with these arguments is that, while Walgreens
presented a fully supported summary judgment motion on the basis that it
had no duty beyond correetly filling a nonobviously fatal prescription, its

motion made only passing reference to breach of duty and causation of
- continued

of action for negligence as a matter of law.”); see also id. at 947 n.2
(compiling similar cases)

 

 

 
injury, and did so mainly in reply. Breach of duty and causation are
classically questions of fact. Frances v. Plaza Pacific Equities, 109 Nev.
91, 94, 847 P.2d 722, 724 (1993); Nehls v, Leonard, 97 Nev. 326, 328, 630
P.2d 268, 260 (1981).

Complicating matters further, the expert depositions were not
completed until after briefing concluded, and the district court rejected the
Klasches’ supplemental opposition even though Walgreens stipulated to
its filing. Given our rejection of Walgreens’ principal argument that it had
no duty as a matter of law, which materially changes the issues presented
by the summary judgment motion, we conclude that potential factual
issues remain that preclude affirming the district court's summary
judgment at this point.

CONCLUSION

By insulating pharmacists from liability for failing to warn
their customers of a medication’s generalized risks, the learned-
intermediary doctrine prevents pharmacists from interfering with the
doctor-patient relationship. Because the public-policy considerations
behind this doctrine are sound, we adopt it in the context of
pharmacisticustomer tort litigation. ‘These public-policy considerations
are less persuasive, however, when a pharmacist has knowledge of a
customer-specific risk with respect to a prescribed medication.
Accordingly, in such circumstances, the learned-intermediary doctrine
does not insulate a pharmacist from liability, and the pharmacist instead
has a duty to exercise reasonable care in warning the customer or
notifying the prescribing doctor of this risk. Because factual issues

remain in this case as to breach of duty and causation of injury, we

 

 
reverse the district court's summary judgment in favor of Walgreens and

remand this case to the district court for proceedings consistent with this

opinion.