How to avoid medication errors
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Q:A patient suffered an allergic reaction to medication because we failed to see the notation in her chart. Fortunately, there weren't any severe consequences. But the incident made me wonder how we can best protect ourselves in the future. Should we institute a policy requiring nurses to double-check before administering any meds? A summary sheet with a box for known allergies? Bright sticky labels for the front of the record?
A: All of these safeguards are wise, but only if you pay attention to them diligently. One New York internist failed to do so, and it cost him plenty. His 93-year-old patient was so severely injured that the doctor's insurer recently settled for $1.6 million after the plaintiff finished presenting her case to a jury. That's an extraordinarily high award for such an elderly patient.
The patient had a suspected urinary tract infection. Her internist and a medication nurse at the senior citizens' residence administered a sulfa drug despite the patient's known allergy.
The internist hadn't paid attention to the clear warning in the chart, and the medication nurse disregarded the home's written protocol for double-checking the chart before administering the drug. And though a large orange sticker indicating an allergy was located on the cover of the patient's chart, the doctor ignored it. As a result, the patient suffered the onset of toxic epidermal necrolytis, which involved the denuding or sloughing off of approximately 50 percent of her skin. She was in tremendous pain until her death about two weeks later.
All the safeguards you suggested were present in this case, but the doctor and nurse failed to use them. In addition to the home's policy for double-checking the chart, there was a summary sheet with check-off boxes. The doctor claims he read it, but the box regarding allergies wasn't checked. (A blank box may be construed as not completed, or else completed with a negative finding. Check boxes can work as reminders, but they must be drafted carefully to avoid this confusion).
The trial judge pointedly noted that a physician has an obligation to ask patients about possible allergic reactions before prescribing any medication. More generally, doctors have a well-established duty to obtain a patient's medical history, and to record any known allergies or adverse reactions to medications and any potential drug interactions. Medical personnel must routinely screen for potential drug interactions and allergic reactions even when medication history is available in the patient record. Before medication or any treatment regimen is prescribed, a specific history that relates to the treatment should be taken and noted in the chart.
Since allergies may be hereditary, you should inquire whether the patient's relatives suffer from particular drug allergies. Ask also whether the patient has a specific condition such as pregnancy or diabetes that may affect medication. After you prescribe the medication, instruct the patient to report any unusual or questionable reactions. If the drug or particular patient warrants, you should actively monitor the patient's reaction.
Lee Johnson. Malpractice Consult. Medical Economics 2001;8:137.