The risk of on-call prescribing

•  Denying a refill request could be dangerous if a patient requires it for a chronic condition.

• If you're on call, speak directly to patients who request medications or refills.

• If you prescribe or refill medications, inform the patient's own doctor as soon as possible.

Q: I'm starting to get nervous about having a covering doctor prescribe medicine for my patients or order refills for them. I'm also concerned about liability when I'm the one who's the covering physician. Is this a serious risk?

A: Yes. Prescribing medications or approving refills for patients can indeed be risky if the on-call physician doesn't have access to the patient's medical history or records, doesn't examine or speak to the patient, or hasn't consulted with the patient's own doctor.

In routine cases, however, approving such requests may be appropriate, and reasonably safe. In fact, denying a refill request could be dangerous if a patient requires medication for a chronic condition like diabetes, hypertension, or cardiac problems.

But prescribing potent medications or approving refills can lead to a disaster if the drug isn't indicated, if it masks symptoms of serious illness, or if it enables a patient to postpone a scheduled visit for necessary exams or tests. If the patient suffers an injury as a result, both the treating physician and the on-call physician could be liable for malpractice.

In one case, an on-call internist authorized a pain reliever refill for a patient whose own doctor had initially prescribed it, but had then refused to order refills because the patient was abusing it. When the drug abuse allegedly contributed to an auto accident, the patient filed a claim for negligent prescribing against the on-call internist.

Balancing a patient's medical needs, the danger of inappropriate medication, and the liability risks isn't easy. But it's certainly less risky than facing a jury in a malpractice case resulting from a medication-related injury.

What can you do to protect yourself? First, you and your colleagues should review your group's prescribing practices and establish guidelines governing on-call physicians. Here are some suggestions:

• Agree to refill certain types of medications for each other's patients, but only in amounts sufficient to carry them until their regular physician is available.

• Agree not to prescribe potent drugs such as pain medications or antidepressants without examining the patient.

• Tell your patients that except in emergencies, colleagues covering for you won't authorize refills of certain drugs on nights, weekends, and holidays. Encourage them to manage their medications responsibly so that they don't run out at an unconvenient time.

• If you're the one on call, speak directly to patients who request medications or refills. Review their symptoms, inquire about other methods to alleviate the problem, and ask how recently the patient has seen his or her own physician.

• Before prescribing anything when you're on call, ask patients to list all medications and OTC preparations they're currently taking.

• If you do prescribe or refill medications when on call, inform the patient's own doctor as soon as possible afterward.

 

David Karp. Malpractice Consult: The risk of on-call prescribing. Medical Economics Aug. 20, 2004;81:62.