Medication Prescribing Errors

Institute of Medicine Issues Report on Medication Errors

The other day in the clinic a patient came in and told me he was recently in the ER with severe hypotension. He had a rough time, they poked him relentlessly to try to find a vein, wound up putting in a central line first in the artery by accident and then finally in the vein and after all that they wound up not needing to use the venous access since his blood pressure was resolving nicely with IV fluids from the initial IV started by the ambulance crew.

He is a patient i was seeing for chronic pain and chronic high level opiate use (pills). I was trying to help him detox off the narcotic medications and I had used a routine medication, Clonidine, (a blood pressure medicine). It is usually started at a fairly high level for people detoxing off opiates and then weaned down as their symptoms of withdrawal ease. He had started it two days prior to his emergency.

Turns out that he had high blood pressure, was already on three blood pressure medications, but i didn't review his medications before starting the new drug. It was in the chart right in front of me. A dumb and potentially dangerous oversight on my part.

I recognized my mistake while he was telling me the story of his ER visit and started to apologize. It is part of my practice philosophy to own my mistakes and apologize, and even to refund money if the person feels harmed by an error. While i was attempting to apologize, he was very kind, and refused to accept my apology. He acknowledged that the error was mine but didn't feel angry. Somehow in the matrix of life, he actually felt even more strongly about getting off the narcotics and was prepared for another round (without the Clonidine) after resting for a month.

While he refused to accept my apology, out of kindness to me, I know he heard it, I could see him relaxing a bit as I acknowledge my error. he felt validated for his fairly rough experience in the ER and the bill he will now have to deal with. Contrary to the fear promoted by insurance companies and professional physician organizations, honest apology works as a powerful form of malpractice protection. most people are reasonable until they feel betrayed or abandoned by their physicians and then they get upset and use whatever tools are available to them to "get even."

This seemed a fairly timely incident to discuss given the most recent report by the Institute of Medicine citing medication errors as a huge cause of morbidity and mortality. You can bet that I read it carefully and will now be more vigilent with my prescriptions. I find their recommendations to be fair and accurate and even useful. see below.

-------

Institute of Medicine Issues Report on Medication Errors


More than 1.5 million patients are estimated to be injured each year
by medication errors, a committee of the Institute of Medicine
reported Thursday.

The committee's report, "Preventing Medication Errors," was written
at the behest of the Centers for Medicare and Medicaid Services,
which intended to estimate the incidence of drug errors and identify
the best preventive strategies against them.

Among the report's recommendations that directly affect physicians:

-- All prescriptions should be written electronically by 2010.

-- Providers should improve communication with patients about how to
take drugs safely and about potential risks.

-- All medication mistakes should be disclosed to patients.

-- Doctors should use electronic decision-support tools to write
prescriptions.

-- Physicians should regularly review all medications with patients
and other providers involved in a patient's care, particularly when a
handoff occurs.

-----