Avoid successful suits alleging prescribing errors
Paper-based prescribing errors are common with primary care practices, according to a recent study which found that 27.8% of 9,385 prescriptions had at least one prescribing error.1 The prescriptions reviewed were for 5,955 patients written by 48 ambulatory care providers in New York and 30 providers in Massachusetts.
Antibiotics had the most prescribing errors, followed by cholesterol medications, narcotic analgesics, and blood pressure drugs. According to the researchers, use of electronic prescribing with a basic clinical decision support system in place could have prevented 32% of prescribing errors, and an advanced system would have prevented 57%. (See story on reducing risks of “alert fatigue,” below.)
Medical malpractice claims involving prescribing errors typically involve prescribing an incorrect medication or prescribing the correct medication at the wrong dose, according to Lisa Lepow Turboff, JD, a shareholder with Munsch Hardt Kopf & Harr in Houston, TX.
Typically, any prescribing error case does not fall exclusively on physicians’ shoulders, says Turboff, as nurses and pharmacists must know the rationale for prescription drugs including basic side effects and dosing information as described in the product labels printed in the Physician’s Desk Reference (PDR). “Nurses and pharmacists are required to question a physician’s prescription that falls outside of those parameters,” she says. “Physicians must be receptive to nurses and pharmacists who question their orders, as these are the medical professions who can catch a mistake and prevent an injury and avoid a lawsuit.”
Here are some liability risks involving drug prescribing:
• Prescribing opioid mediation following surgery.
“Typically, opioids are prescribed to control post-surgical pain,” says Turboff. “However, they are known respiratory depressants, which could cause decreased breathing in the patient.”
When patients suffer adverse outcomes related to opioid prescriptions, physicians are typically sued on the basis of either not prescribing a weaker mediation initially before defaulting to an opioid, or prescribing the opioid to be given at too-short intervals, says Turboff.
• Prescribing a drug to which the patient is allergic.
Although it’s rare for physicians to prescribe penicillin to a patient known to be allergic to penicillin, it’s not infrequent that a similar drug might be prescribed that should be avoided in the penicillin-allergic patient, such as ampicillin and sulbactam, says John Davenport, MD, JD, physician risk manager of a California-based HMO. Similarly, erythromycin-sulfisoxazole might be given inadvertently to a sulfa-allergic patient. “Drug references, the PDR, and your local pharmacist are valuable resources to help avoid allergy cross-reactivity,” he advises.
• Prescribing a drug that interacts with a drug the patient is taking.
“Drug interactions with the blood thinner warfarin, and subsequent bleeding, are a common cause of malpractice,” says Davenport. “One must be wary of prescribing many drugs to patients on warfarin.”
Certain combinations of many common drugs, including selective serotonin reuptake inhibitors, fluconazole, clopidogrel, and anti-inflammatory agents can put patients at risk for bleeding, says Davenport.
“Drug lists that patients present to us are often daunting and inaccurate. But your legal duty is to be aware of the information at hand, including the drugs the patient is on, before prescribing,” says Davenport. “Seek out the information a reputable physician in a similar situation would seek out prior to prescribing.”
• Overprescribing pain medications.
Malpractice cases and medical board actions are increasingly directed at physicians who prescribe excessive amounts of pain medications without adequate examinations, supporting diagnoses, and proper monitoring, warns Davenport. “When pain became the ‘fifth vital sign,’ physicians were encouraged to use whatever pain control was necessary to alleviate pain,” he says. “With an increasing incidence of overdose, addiction, and drug diversion, the pendulum is swinging back.”
Reference
- Abramson EL, Bates DW, Jenter C, et al. Ambulatory prescribing errors among community-based providers in two states. J Amer Med Informatics Ass 2012; 19;644-648.
Sources
For more information on claims involving prescribing errors, contact:
- John Davenport, MD, JD, Irvine, CA. Phone: (714) 644-4135. Email: [email protected].
- David Troxel, MD, Medical Director, The Doctors Company, Napa, CA. Email: [email protected].
- Lisa Lepow Turboff, JD, Munsch Hardt Kopf & Harr, Houston, TX. Phone: (713) 222-4041. Fax: (713) 222-5813. Email: [email protected].
Did you override an EMR alert? Be prepared to explain why Do you routinely ignore warning prompts given by an electronic medical record (EMR)? The alerts, given when providers prescribe a drug to which the patient is allergic, or for which there is an interaction, do increase safety, says John Davenport, MD, JD, physician risk manager of a California-based HMO, “but in order to avoid their own liability, the allergies and interactions programmed into these systems tend to be exhaustive and often include trivial or rare reactions.” This factor often causes “alert fatigue” — the automatic overriding of a warning prompt by providers, says Davenport. “When you override a warning prompt, be prepared to answer the trial question, ‘Isn’t it true that your computer record warned you that the drug you were prescribing could cause a reaction with this patient’s medication?’” he advises. Ideally, says Davenport, the physician can truthfully respond that he or she was aware and judged the interaction or potential allergy to be trivial. Davenport recommends giving feedback to the EMR provider to help them design and fine-tune more reasonable alerts. Another potential legal risk involves the ease with which EMR prescriptions can be refilled, says Davenport. Though a medication might be refilled with just one click, it still is the physician’s responsibility to know that the drug being refilled is the proper drug in the proper amount for the patient’s condition, he advises. “A common fact pattern seen in litigation is failure to monitor a prescription drug — liver function when refilling statins, or electrolytes when refilling diuretics, for instance,” says Davenport. “The ease of EMR prescription refills contributes to this.” |
Most drug error claims involve narcotics According to a 2011 analysis of 2,646 malpractice claims from all medical specialties closed at The Doctors Company in Napa, CA, 5.8% contained medication-related errors. Of these, 18% included narcotic analgesics, with hydrocodone accounting for eight claims (27% of the total). Hydrocodone is the most widely prescribed pain medication in the United States, and a Food and Drug Administration (FDA) panel voted to tighten restrictions on prescribing it in January 2013. “If the FDA accepts the panel’s recommendation, it will go to the Department of Health and Human Services for final approval. Refills without a new prescription would be prohibited, and only written prescriptions from a physician would be permitted,” says David Troxel, MD, medical director of The Doctors Company. If this restriction is subject to an “FDA Alert,” it will become the standard of care, and if an adverse drug event results from violating it, the physician might be held liable, says Troxel. Many of the professional liability claims involved adverse events that occurred in the post-anesthesia care unit, intensive care unit, or critical care unit and involved pain medicine overdose, failure of communication between prescribers of pain medications, and inadequate monitoring of patients receiving pain medications, says Troxel. “The most common adverse event is respiratory depression, often in patients with unrecognized obstructive sleep apnea,” says Troxel. “This can result in the need for ventilator support and sometimes in death.” Compared to medication-related errors in all claims, monitoring, administration, and ordering errors were more common in claims involving narcotic analgesics, according to the analysis. “A common contributor to these adverse drug events is failure of communication, sometimes resulting in poor coordination of care between physicians, often during hand-offs, and between physicians and nurses, often during shift changes,” says Troxel. “Hopefully, monitoring protocols, e-prescribing, and [electronic health record] drug alerts will obviate this problem.” Difficult position Troxel has seen patients’ allegations of overprescribing opioids for chronic pain management result in a medical board action against the physician. “Physicians are put in a difficult position,” he says. “They can be sanctioned for overprescribing opioids, resulting in dependency or addiction, and they can be criticized for failing to prescribe sufficient opioids to relieve patient pain and thereby causing pain and suffering.” Troxel advises physicians who prescribe opioids to take the FDA’s Risk Evaluation and Mitigation Strategy (REMS), a three-hour online course on long-acting and extended-release opioids. (For more information, go to http://1.usa.gov/qiruyI.) “REMS covers three basic components: Prescriber training to ensure safe use, patient counseling on safe use and risks, and a medication guide for each opioid, which patients receive when prescriptions are filled,” says Troxel. |
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