RMF Teaching Case M8-1 - Download
Patricia Smith undergoes reconstructive orthopedic surgery. Post-operatively, she is placed on 5 mg of Warfarin daily. One month later, she presents to her primary care practitioner, Dr. Hart, with complaints of pain and inflammation at the incision site. Deep wound cultures are taken and candida albicans is identified as the causative organism.
Dr. Hart recognizes that Fluconazole is the drug of choice for treating this type of candidal infection. Given Ms. Smith's presentation, what should Dr. Hart do next?
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RMF Teaching Case M8-2 - Download
Carl Jones, a patient with seasonal affective disorder, is prescribed a new medication, Nortriptyline 50 mg at bedtime. Dr. Li's chart notes indicate in general terms that risk and benefits were explained. The dose is gradually increased to 75 mg and then 100 mg daily. While working on an elevated platform, Mr. Jones stands quickly and suffers an orthostatic hypotensive episode—the severity of which is later attributed to the medication's side effects. He falls ten feet and is severely injured.
What actions could the provider have taken to decrease the likelihood of this injury occurring?
RMF Teaching Case M8-3 - Download
Rosette Ruiz, a 77-year-old woman with a recurrent urinary tract infection, is referred by her primary care provider to Dr. Simmons, a urologist, who prescribes Macrodantin (nitrofurantoin) as prophylactic antimicrobial therapy. There is no documentation in the patient's chart that Mrs. Ruiz has been informed of the risks associated with long-term use of Macrodantin.
Mrs. Ruiz later presents to her primary care provider, Dr. Henri, with complaints of cough and possible upper respiratory tract infection. Dr. Henri is unaware that Mrs. Ruiz is on chronic prophylactic Macrodantin therapy. Unable to diagnose the condition, Dr. Henri refers Mrs. Ruiz to a pulmonologist. The pulmonologist is also unaware that the patient is on prophylactic Macrodantin therapy and diagnoses a benign viral respiratory infection.
One year later, the urologist, Dr. Simmons, continues to renew the Macrodantin prescriptions without monitoring the patient for potential pulmonary toxicities. Mrs. Ruiz subsequently develops fibrosis and bronchiectasis due to Macrodantin toxicity, and dies.
RMF Teaching Case M8-4 - Download
A physician orders mycostatin vaginal suppositories for 48-year-old Ellen Orland. The nurse administers the suppository vaginally, as intended by the manufacturer. The next day the nurse discovers that the prescriber intended the medication to be used orally for a fungal infection in Ms. Orland's throat. She is not harmed, but did not initially receive the appropriate therapy.
The type of error that Ms. Orland encountered can be avoided by:
RMF Teaching Case M8-5 - Download
James Elizabeth brings suit against a prescriber claiming that he was injured because the prescriber treated him with a higher dose than that recommended in the package insert. His physician argues that the dosage did not deviate from the standard of care, even if it differed from the information found on the company literature. The court rules in favor of the physician, commenting that the package insert alone did not represent the standard of care.
RMF Teaching Case M8-6 - Download
At 18 weeks into her second pregnancy, 27-year-old Marilyn Grace's vaginal swab is positive for group B streptococcal infection (GBS). Untreated, this will result in neonatal sepsis. Penicillin and ampicillin have not been approved for use in pregnant women.
Nevertheless, the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics adopted a 1996 CDC guideline that recommends the administration of intrapartum penicillin or ampicillin prophylaxis if the rectal/vaginal swab is positive for GBS. 1, 2 Failure to adhere to these guidelines may be considered negligent.
Cardwell M. Preventing perinatal early-onset of GBS: the new standard of care. Journal of Legal Medicine. 1997; 511. Rayburn WF and Farmer KC. Off-label prescribing during pregnancy. Obstetrics and Gynecology Clinics of North America. 1997: 24(3); 471–478.
RMF Teaching Case M8-7 - Download
Jeremy is a four-year-old patient who was diagnosed as having ADD at age 2. His pediatrician referred him to a behavioral specialist after failing a Ritalin trial. After a lengthy discussion with the parents about the benefits and risks involved with a new medication therapy, Jeremy was started on clonidine.
Jeremy was started on a 1/2 tablet daily and progressed to a dose of 1.5 tabs QID and 2 tabs qhs, a total daily dose of 0.8 mg. In addition, Jeremy was referred to a sleep specialist to be evaluated for sleep disturbances. After evaluation and discussion with the parents, chloral hydrate was ordered in progressive dosing to a final dose of 4 tsp. qhs, for a daily dosing of 2000 mg.
Jeremy’s care and medication regime was handled by the pediatrician over the next few years. Jeremy’s specialist care was episodic and handled mostly by phone. At age five Jeremy’s sleep pattern began to deteriorate and the parents called the pediatrician requesting advice. The pediatrician authorized an additional dose of chloral hydrate if Jeremy was still awake at 3:00 A.M. Over the next four months Jeremy was often awake at 3:00 A.M.
Five months after the increased dose of chloral hydrate, Jeremy passed away of a cardiac arrhythmia. The autopsy report stated the cause of death as “unexpected, unintended effects of the medication he was on for the treatment of pervasive behavioral disorder.”
A review of the medical record reveals:
RMF Teaching Case M8-8 - Download
Mr. Penny, a long time patient of Dr. Small, had been maintained on Coumadin, 7.5 mg since his heart attack six years ago. At age 62, the patient was admitted to the hospital with a GI bleed. His Protime was >50, with an INR of 22.2 (approximately 10 times greater than normal). One week prior to admission, Mr. Penny received from Dr. Small a prescription for Coumadin 10, 30 mg po QD, refills x 3. The prescription was called to the pharmacy by the medical secretary and a hard-copy was faxed. The prescription was filled and dispensed as warfarin instead of Mr. Penny’s usual Coumadin. No contact was made by the pharmacist to Dr. Small prior to filling and dispensing the medication.
