|
CASE OF THE MONTH:
No Prescription is Routine
By Gordon Ownby
CAP-MPT's General Counsel
When the Institute of Medicine issued its report, “To Err is Human,” the single
largest area targeted for improvement was that of medication-related mistakes. The authors
explained that medication-related error has been studied extensively for several reasons:
“It is one of the most common types of error, substantial numbers of individuals are affected,
and it accounts for a sizable increase in health care costs.”
One case shows just how much an error in a simple prescription renewal can cost.
The 63-year-old patient had treated with Dr. A, an internist, for five years. Some
three years before that, the patient had undergone a heart valve replacement for endocarditis
at a large HMO.
One day, the patient’s wife was in to see Dr. A and told him that her husband
needed refills for his medications, including Coumadin. Without looking at the patient’s
chart, Dr. A wrote out a prescription for “Coumadin, 5-mg., use as directed.” When the
prescription was filled at the chain pharmacy, the label was typed, “Take 1-1/2 tablets by
mouth as directed.”
What Dr. A did not recall when he wrote the prescription was that the patient’s
long-standing regimen, as originally prescribed at the HMO, was to take 2-mg. tablets of
Coumadin three times daily. When he got the new prescription, the patient did not notice
that the color of his pills was different and proceeded to take the 5-mg. tablets in his usual
three-times daily routine.
In fact, Dr. A himself had long been renewing the patient’s Coumadin using 2 mg.
tablets, (the dosage that originated at the HMO) even though his normal practice is to
prescribe his patients 5 mg. tablets, once daily.
The patient began taking the 5 mg. tablets three times a day and then left on an
overseas trip with his refill. During his travels, the patient first noticed unusual bleeding
from his gums, but continued with the thrice daily intake. The patient then developed a
large hematoma over his buttock and had to be hospitalized in the foreign country. Once
stabilized, the patient flew back to California and was hospitalized locally for five days.
(Unfortunately, the medication error was not diagnosed abroad, and the patient again
experienced bleeding during the flight after he resumed taking 5 mg. tablets.)
Fortunately, the episode resolved with the patient’s local hospitalization with no
adverse long-term effects.
In retrospect, Dr. A relied on his custom and practice (5 mg. tablets for all his
patients) for the refill even though this patient fell outside that custom and practice.
Compounding the oversight was the pharmacy’s failure to note the change in dosage coupled
with its re-worked label instructions.
As medical and public safety leaders work on their response to the Institute of
Medicine’s call for a dramatic reduction in medication mistakes, it appears that technology
may play a role in preventing prescription errors. Hand-held devices now being introduced
have the capability to warn physicians of adverse interactions, to print out prescriptions,
and even to send prescriptions to pharmacies electronically.
Even when such devices become common, however, a case such as this demonstrates
that no prescription should be considered routine.
|
