Medical Professionals Reference (MPR)Physician Can’t Evade Lawsuit, Although He Never Even Saw Patient

Systemic Failures in Medication Safety: When Paper Forms and Lack of Protocols Lead to Patient Harm

A recent legal case highlights the critical importance of robust medication safety protocols in healthcare settings. The case involves a patient who suffered a severe allergic reaction after being prescribed a sulfa drug, despite noting her allergy on an intake form. The potential consequences of relying on paper-based systems and the absence of computerized alerts for contraindications can be devastating for a practice.

Key Points:

• A patient (Mrs M) sought treatment at a walk-in clinic and noted her sulfa allergy on a paper intake form.
• The nurse practitioner (Ms N) prescribed sulfamethoxazole/trimethoprim, a sulfa drug, apparently overlooking the patient’s noted allergy.
• The clinic lacked a computer-based system to alert providers about contraindicated medications.
• The pharmacy filled the prescription without checking for contraindications.
• Mrs M experienced a severe allergic reaction, requiring a two-week hospitalization.
• Mrs M filed lawsuits against Ms N, the walk-in clinic, the pharmacy, and Dr O (the supervising physician).
• The patient’s expert witnesses criticized the lack of protocols to prevent medication errors.
• Mrs M settled with the walk-in clinic and Ms N for $325,000.
• The appeals court dismissed the case against the pharmacy but allowed it to proceed against Dr O.
• Dr O was held individually liable for “failing to have an acceptable computer-based alert system” for contraindications.
• The court ruled that Dr O could be held responsible despite never having seen the patient.
• The case highlights the importance of implementing and following medication safety protocols.
• Healthcare providers should ensure that patient-reported allergy information is actively used and incorporated into prescribing decisions.

Given previous estimates of serious or life-threatening potential adverse drug events (ADEs) of 1.33 per 100 medication doses administered, in a hospital where 6 million doses are administered per year, about 4000 preventable ADEs would be attributable to medication administration errors annually. (BMJ Qual Saf)

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