Failure to Properly Communicate Change in Coumadin Dosage

And other malpractice news
May 2015, Vol 3, No 5 - Malpractice News

In This Article

Failure to Properly Communicate Change in Coumadin Dosage

The Case
The plaintiff’s decedent was placed on Coumadin in January 2002 due to her chronic pulmonary emboli. Dr Heather Heiman with Northwestern Medical Faculty Foundation became the decedent’s primary physician in August 2004.

In January 2005 Dr Heiman saw the 80-year-old decedent for a follow-up visit after a recent hospitalization for heart failure and shortness of breath. Dr Heiman ordered a blood draw to check international normalized ratio (INR) levels, which came back at the elevated level of 3.7. Dr Heiman sent an email to nurse Susan Brankle to contact the decedent and inform her to reduce her Coumadin. Nurse Brankle documented that she informed the decedent and called in a prescription for 4 mg tablets.

The decedent was admitted to a hospital 5 days later with significantly elevated INR levels and a spinal bleed which caused paralysis. She was transferred for nursing home care and died in June 2005.

The plaintiff claimed that Dr Heiman’s instructions were ambiguous, that a repeat INR should have been performed in 2 or 3 days, and that Brankle did not properly instruct the decedent, and that Brankle should have notified the family and the visiting nurse of the medication change. The defendant claimed that Dr Heiman had given proper instructions and that the plan to repeat the INR in 13 days was proper. Nurse Brankle also claimed that the decedent was properly instructed. The defendants also claimed that the decedent had properly managed her Coumadin through 11 dose changes, so there was no reason to notify the family or visiting nurse.

The Verdict
Settlements were reached prior to trial with the other hospital for $5000 and 2 physicians for $35,000. A defense verdict was returned after trial.

Estate of Alice Bowen, deceased v. Northwestern Medical Faculty Foundation. Cook County, IL. Circuit Court, Case No. 07L-6249.

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Failure to Have Man Go to the Emergency Room When Wife Reports Lethargy

The Case
The plaintiff’s decedent had suffered from chronic pain since 1999 due to severe peripheral vascular disease. He received treatment from numerous pain medicine specialists at various times during the ensuing 10 years. The treatment included non-narcotic pain medications, as well as narcotic pain medications, including morphine, oxycontin, fentanyl, hydrocodone, and methadone. On several occasions during those years the decedent ingested more than the prescribed narcotics, which necessitated hospitalizations.

The decedent began treatment with family practice physician John A. Panozzo in June 2004 while also continuing treatment with pain specialists. In April 2009 the decedent was diagnosed with a kidney stone and Dr Panozzo referred him to a urologist. A lithotripsy procedure was performed by the urologist to dissolve the stone and the decedent developed postoperative bleeding outside his kidney. The decedent took his narcotic medications at home for the pain, including hydrocodone and oxycontin. The pain, however, persisted and he went to an emergency room and was hospitalized. The decedent subsequently developed respiratory depression after more pain medication was administered in the emergency room and he required intubation. After the plaintiff was extubated he complained of severe pain and threatened to leave the hospital against medical advice. Dr Panozzo then prescribed a Duragesic Fentanyl patch which was intended to be on for 72 hours and then be replaced with a new patch. Dr Panozzo also prescribed oral narcotics as needed for breakthrough pain, as well as an anti-anxiety medication. During the remainder of his hospitalization the decedent had no breathing problems while awake or asleep while receiving supplemental oxygen and monitoring.

The decedent was discharged home and the next day the decedent’s wife called Dr Panozzo reporting that the decedent looked tired, lethargic, and glassy-eyed and she questioned his medications. Dr Panozzo claimed that he told the woman to take off the Fentanyl patch without replacing it, discontinue Ativan which the decedent had been prescribed, as well as all narcotic medications and then monitor the decedent. Dr Panozzo also claimed that the wife was told to take the decedent to an emergency room if he worsened. The wife disputed Dr Panozzo’s version of the conversation. After the call the decedent did not get worse or exhibit any breathing problems before he went to sleep around midnight. He was found dead in bed the next morning.

The plaintiff claimed that Dr Panozzo should have instructed the wife to take the decedent to the emergency room immediately at the time of her call the previous night. The plaintiff claimed that the combination of the drugs the decedent was using caused a synergistic heightened risk of respiratory distress and that the risk of respiratory distress increased while he was asleep, which with his COPD and presumed sleep apnea caused his death.

The defendant claimed that the decedent did not suffer respiratory distress in the hospital and that he was on less medications after his discharge than while he was in the hospital. The defendant maintained that the decedent must have taken additional narcotics from his home supply contrary to instructions, since his oxycontin supply could not be accounted for after his death.

The Verdict
A defense verdict was returned.

Estate of Wayne Stahr, deceased v. Dr John A. Panozzo, Primary Health Associates, PC. Cook County, IL. Circuit Court, Case No. 11L-4482.

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Failure to Monitor Woman’s Use of Fentanyl Patches in Light of History of Drug Abuse

The Case
The plaintiff’s decedent, age 34, died from an overdose of Fentanyl in September 2001. The Fentanyl had been prescribed to her by pain management physician Narinder Khosla. Several weeks prior to her death, the decedent had been hospitalized after she was found chewing on Fentanyl patches. At that time the decedent’s psychiatrist, Gregory Bishop, was consulted and recommended inpatient substance abuse, which the decedent refused. The decedent was then discharged from the hospital with orders to follow-up with Dr Bishop and to discontinue use of Fentanyl.

The decedent returned to Dr Khosla, who was unaware of the hospitalization, and provided the decedent with another prescription for Fentanyl patches. The decedent’s death was due to chewing on the patches.

The plaintiff claimed that Dr Khosla was negligent in providing the decedent, a long-time drug abuser and addict, with the Fentanyl patches. The plaintiff also alleged negligence by Dr Khosla in failing to refer the decedent to an addictionologist and failing to perform urine drug screens while the decedent was in his care. The plaintiff claimed that Dr Bishop was negligent in failing to inform Dr Khosla of the hospitalization and order to discontinue the use of the Fentanyl.

The defendants denied liability, arguing that the decedent’s mother was aware that the decedent had been chewing on patches the day before her death and made no effort to contact a medical provider.

The Verdict
A defense verdict was returned.

Linda Newman, Adminx of the Estate of Sarah Serrano v. Pain Clinic of North Central Ohio, Inc, et al. Erie County, OH. Court of Common Pleas, Case No. 2012CV0750.

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Reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, Nashville, Tennessee, 800-298-6288.

Stakeholder Perspective
Take-home points
Donald J. Dietz, RPh, MS

Donald J. Dietz, RPh, provides insight on the role of pharmacists in medical malpractice Several messages resonate from these unfortunate cases that resulted in 3 patients losing their lives. The healthcare providers in these cases appeared to be well-meaning, and believed they made rational, appropriate medical decisions based on their knowledge of their patients’ respective situations.

As pharmacists, physician assistants, and nurse practitioners, we may want to consider these learning opportunities for future encounters with patients:

  • Always ask your patient what other medications they are taking, to ascertain whether multiple prescribers are treating them, and because they may be receiving multiple prescriptions to treat the same condition.
  • Ensure all telephone communications are as clear as possible, with no possibility for misinterpretation. When receiving a phone-in prescription order, always transcribe it immediately, and always repeat it back to the caller for confirmation. If it does not make good clinical sense, or if there is any doubt when you prepare to dispense the prescription later, please call the prescriber back to confirm.
  • As more electronic health record/electronic medical record (EMR) systems are incorporated into practice, it is essential to completely document interventions, including follow-up treatments and lab tests.
  • Prescribers accessing EMRs to prevent duplicate medications and testing will lower healthcare costs and potentially reduce adverse outcomes. Pharmacists, physician assistants, and nurse practitioners should welcome and strive for access to EMRs, to provide better, more comprehensive patient care.
  • These examples demonstrate that it is worth the extra time and effort to communicate instructions to another family member, caregiver, or supporting healthcare practitioner when you are unsure whether a patient understands or will follow the medication instructions or treatment prescribed.
To avoid situations like these during future patient encounters in our pharmacies or clinics, we may want to consider extra steps for providing necessary, important communication to ensure positive outcomes.

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