Some hospitals are set up to allow physician medication errors
The U.S. Food & Drug Administration (FDA) says that medication errors cause at least one death a day and injure 1.3 million people a year
When the government encouraged, and later forced, hospitals to transition to electronic medical records, one of the big selling points was that they would reduce medication errors. Now that electronic medical records systems are widely used at hospitals all over Texas and nationwide, experts agree that they have had little to no impact on reducing adverse drug events in hospitals.
In a recent podcast by the Journal of the American Medical Association (JAMA), a physician from the University of Texas Southwestern Medical Center, in Dallas, Texas shared details about a scary medical error that left a patient unresponsive for days.
It all started when a man in his 60s came to the hospital with classic symptoms of chronic obstructive pulmonary disease (COPD) exacerbation. In addition to having a past medical history of COPD, the man also had epilepsy.
For the four days prior to his arrival at the hospital emergency room, he had been short of breath and had increased sputum (a mix of saliva and mucus coughed up from the respiratory track) production and appearance. When the doctor examined the patient, he noted that he was wheezing.
While in the emergency room, the patient was diagnosed with pneumonia and was admitted to the hospital. When his respiratory condition deteriorated, the medical team sedated and intubated (placed a breathing tube) him.
After his condition started to stabilize, his doctors wanted to arouse him from sedation and extubate (remove the breathing tube) him. The problem was that they could not get him to wake up, even after taking him off all sedatives and pain medications.
The doctors studied lab results and ran down numerous ideas of what could be causing this serious problem, to no avail. Then they started looking at secondary issues, like medications, when they found something alarming.
When the medical team reviewed the patient’s medications and medication history, they discovered that a terrible mistake had happened.
While at home, the man orally took 300 mg of an anti-epileptic/anti-seizure drug called phenytoin (Dilantin), once a day. Once he was admitted to the hospital, he was prescribed and 300 mg of the same drugs three times a day—three times the correct dose, which is way more than a safe dosage.
This poor man could not wake up because he had been overdosed with phenytoin and developed phenytoin toxicity. That is a dangerous condition that triggers a succession beginning with altered mental status that can progress to seizures and even death. The doctors stopped all phenytoin and, fortunately, four days later the man woke up and fully recovered.
What caused the medication error?
The hospital realized that this was a serious mistake and did a root cause analysis to figure out why it happened. They found three major problems: (1) gaps medication reconciliation; (2) the admitting doctor who wrote the prescription did not understand how the electronic medical record system worked; and (3) the order entry system was difficult and had not been updated.
Medication reconciliation is the process where a hospital’s staff assembles a list of all medications that a patient was taking prior to admission, including the medication name, dosage, and how often it was taken each day. Experts know that there are often gaps in the medication reconciliation because most electronic medical record systems do not communicate with outside pharmacy or insurance systems that contain that information.
Hospitals could improve the medication reconciliation process by upgrading their electronic medical records software to be able to access medication data in other systems.
I recommend that patients keep a complete, current list of all medications, including the drug name, dosage, and how often it is taken, as well as the name of the doctor who prescribed it, and the name and phone number of the pharmacy where it was filled. Providing such a list to your doctor or nursing staff upon admission to a hospital can help to ensure that your medication records are accurate.
Confusing computer system
The doctor who admitted this patient wrote an order for 300 mg of Dilantin, which matched the amount that the patient was taking at home. The doctor was not properly trained on the electronic medical record system at the hospital, though, and, thus, did not realize that the computer would automatically make the order for that dose to be taken three times a day.
The hospital’s computerized system may have been programmed that way because most patients who are started on phenytoin with a dosage of 100 mg three times a day. When the patient becomes stable, it is increased to 300 mg once a day.
One way to fix this type of error is to require the doctor to specify the dose and frequency in the order, rather than having the electronic medical record system auto-populate parts of the order.
Another way is for the hospital to have a better system with an added layer of patient safety. After all, this is a big problem. A research pharmacist at the U.S. Centers for Disease Control and Prevention, Atlanta, said that medication errors are the most common types of voluntary reports to the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO).
Experts recommend that hospitals revamp their systems by starting with a list of medications that have a narrow therapeutic index or have a high risk of causing complications. In other words, medications like Dilantin and Warfarin, where dosage and frequency have to be extremely precise, would certainly be on the list.
Once the dangerous drugs list is in place, experts recommend that hospitals configure their electronic medical records system to generate an automatic referral to the hospital pharmacy any time a doctor writes an order for one of the drugs. Then the pharmacy would step in to ensure that the dosing of the medication is correct, and then to implement monitoring of the patient’s liver and kidney function to make sure that the drug is metabolizing properly. With the pharmacy department involved, it provides added continuity of care throughout the hospitalization.
It’s everyone’s fault
The JAMA podcast is entitled “Medication Errors in Hospitals—It’s Everyone’s Fault.” I could not agree more.
The doctor who ordered the medication for this man certainly bears some responsibility for the mistake, but not all of it.
Hospital administrators are responsible for creating conditions where patients can receive care without being exposed to a risk of errors.
Was there adequate staffing in place to make sure the doctor was not overworked?
Did the hospital create systems within the electronic medical records system to facilitate the doctors’ work and avoid errors?
Did the hospital have a policy in place to the pharmacy department involved to verify medication dosages and monitor patient wellness?
Then there is the issue of unsafe supervision. When doctors and nurses are not properly trained on how to execute complicated tasks, such as electronic medical record orders and entries, it places patients in a position of needless risk.
We are here to help
The medical malpractice attorneys at Painter Law Firm, in Houston, Texas, are experienced in handling cases involving serious injuries or wrongful death caused by medication errors in hospitals or by a pharmacist. Call 281-580-8800 for a free consultation about your potential case.
Robert Painter is a lawyer at Painter Law Firm PLLC, in Houston, Texas, where he handles all kinds of medical malpractice cases. He has extensive experience in investigating and pursuing negligence cases arising from medication errors by hospitals, pharmacies, and doctors that have caused seriously injuries or death. Medication errors cases may involve a variety of different drugs, including opioid painkillers, like Dilaudid, as well as cardiac, respiratory, and sedating drugs.
Robert Painter is a medical malpractice lawyer at Painter Law Firm PLLC.
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Published in the July/August 2018 edition of "The Houston Lawyer" magazine