After surgery to repair a congenital abnormality of his biliary tree, a 34-year-old male patient suffered from repeated episodes of obstruction and infection. During one of several post-operative hospital admissions for infection, he received a small dose of cefotetan. The patient had an anaphylactic reaction that was treated quickly with good results. Cefotetan was added to the list of medications to which the patient was allergic, which also included Compazine. On his physician’s advice, the patient began wearing a medical alert bracelet indicating his drug allergies.
Two months later, during another admission, the patient was given Compazine for nausea. When the patient questioned the nurse after the injection, he received Benadryl in time to mitigate his allergic reaction.
Four months later, after a second surgery, the patient was readmitted for a post-op infection, and ofloxacin was ordered. When asked to consult on the patient’s post-op care, an Infectious Disease specialist—apparently unaware of his allergy—changed the order to cefotetan, which the patient received and reacted to adversely. He was stabilized and admitted to the ICU for overnight observation. The next day, the patient refused to be admitted to the floor where the drug error occurred.
The patient filed a claim against the institution alleging multiple incidents of negligence regarding the ordering and administration of medication.
This claim was settled in the low range (<$99,999).
- This case involved multiple errors involving common factors (i.e., same patient, same drugs) but different providers. When different people repeat the same mistake, the blame should fall on the systems they are relying on to prevent such errors from occurring (even once).
Everyone along the medication path needs a system of checks and double checks to ensure that the patient receives the right amount of the right drug in the right manner at the right time(s).
- The patient had chronic health problems, and multiple hospital admissions. Without his own intervention and watchfulness, more errors—and more serious consequences may have resulted.
Patients who know a lot about their health care are key members of the health care team. Physicians and nurses who engage such patients in all aspects of chronic care reduce the likelihood of error. If and when errors, or potential errors do occur, the patient who is comfortable communicating with caregivers is more likely to be an ally than an adversary.
- After experiencing multiple errors, or near errors, the patient in this case refused to be admitted into what he perceived to be a risky setting, perhaps avoiding one risk, but potentially creating another risk by being placed in a less suitable unit.
A patient who expresses distrust—or, worse, fear—of a particular procedure, clinician, or setting may raise the stakes for a potential complaint, malpractice claim, or lawsuit. Anything short of taking such concerns seriously and addressing them appropriately invites the perception that the patient is being mistreated. Any problems that ensue after a patient has expressed such concerns or fears, can easily be perceived as verification of his or her trepidation.
Written by CRICO/RMF Staff
