Avoid successful suits alleging prescribing errors
(Editor’s note: This issue includes the first part of a two-part series on prescribing errors. In this issue, we address liability risks. In next month’s issue, we discuss liability with narcotics and also "alert fatigue" with electronic medical records.)
Paper-based prescribing errors are common with primary care practices, according to a recent study which found that 27.8% of 9,385 prescriptions had at least one prescribing error.1The prescriptions reviewed were for 5,955 patients written by 48 ambulatory care providers in New York and 30 providers in Massachusetts.
Antibiotics had the most prescribing errors, followed by cholesterol medications, narcotic analgesics, and blood pressure drugs. According to the researchers, use of electronic prescribing with a basic clinical decision support system in place could have prevented 32% of prescribing errors, and an advanced system would have prevented 57%.
Medical malpractice claims involving prescribing errors typically involve prescribing an incorrect medication or prescribing the correct medication at the wrong dose, according to Lisa Lepow Turboff, JD, a shareholder with Munsch Hardt Kopf & Harr in Houston, TX.
Typically, any prescribing error case does not fall exclusively on physicians’ shoulders, says Turboff, as nurses and pharmacists must know the rationale for prescription drugs including basic side effects and dosing information as described in the product labels printed in the Physician’s Desk Reference (PDR). "Nurses and pharmacists are required to question a physician’s prescription that falls outside of those parameters," she says. "Physicians must be receptive to nurses and pharmacists who question their orders, as these are the medical professionals who can catch a mistake and prevent an injury and avoid a lawsuit."
Here are some liability risks involving drug prescribing:
• Prescribing opioid medication following surgery.
"Typically, opioids are prescribed to control post-surgical pain," says Turboff. "However, they are known respiratory depressants, which could cause decreased breathing in the patient."
On those rare occasions where the patient actually stops breathing, physicians are typically sued on the basis of either not prescribing a weaker medication initially before defaulting to an opioid, or prescribing the opioid to be given at too-short intervals, says Turboff.
• Prescribing off-label.
If a physician is prescribing off-label, the patient’s chart should reflect this fact so that the physician can better explain his or her medical judgment in a subsequent lawsuit, says Turboff.
• Prescribing a drug to which the patient is allergic.
Although it’s rare for physicians to prescribe penicillin to a patient known to be allergic to penicillin, it’s not infrequent that a similar drug might be prescribed that should be avoided in the penicillin-allergic patient, such as cefuroxime axetil or ampicillin and sulbactam, says John Davenport, MD, JD, physician risk manager of a California-based HMO. Similarly, erythromycin-sulfisoxazole might be given inadvertently to a sulfa-allergic patient.
"Drug references, the PDR, and your local pharmacist are valuable resources to help avoid allergy cross-reactivity," Davenport advises.
• Prescribing a drug that interacts with a drug the patient is taking.
"Drug interactions with the blood thinner warfarin, and subsequent bleeding, are a common cause of malpractice," says Davenport. "One must be wary of prescribing many drugs to patients on warfarin."
Certain combinations of many common drugs, including selective serotonin reuptake inhibitors (SSRIs), fluconazole, clopidogrel, and anti-inflammatory agents can put patients at risk for bleeding, says Davenport.
"Drug lists that patients present to us are often daunting and inaccurate. But your legal duty is to be aware of the information at hand, including the drugs the patient is on, before prescribing," says Davenport. "Seek out the information a reputable physician in a similar situation would seek out prior to prescribing."
• Overprescribing pain medications.
Malpractice cases and medical board actions are increasingly directed at physicians who prescribe excessive amounts of pain medications without adequate examinations, supporting diagnoses, and proper monitoring, warns Davenport.
"When pain became the fifth vital sign,’ physicians were encouraged to use whatever pain control was necessary to alleviate pain," he says. "With an increasing incidence of overdose, addiction, and drug diversion, the pendulum is swinging back."
1. Abramson EL, Bates DW, Jenter C, et al. Ambulatory prescribing errors among community-based providers in two states. J Amer Med Informatics Ass 2012; 19;644-648.