Ordering improper medication

Presentation
A 40-year-old man with a history of a Grade 4 gliosarcoma underwent a left parietal craniotomy at Hospital A. After the craniotomy at Hospital A, the patient had received two five-day courses of 400 mg of the chemotherapy drug temozolamide ordered by his oncologist. Temozolamide is typically given in 150 mg doses for five-day cycles every 28 days for up to six cycles, with a complete blood count to be taken between cycles.

The patient came to the emergency department (ED) at Hospital A after experiencing intractable seizures. The patient was admitted to Hospital A, and imaging studies identified a recurrent brain tumor in the left parietal lobe. The history and physical for the admission listed the patient’s medications and stated the patient had also taken temozolamide “400 mg daily x 5.” The patient’s family was upset about the tumor’s reoccurrence, and requested a transfer to Hospital B for a second opinion and treatment.
 

Physician action
At Hospital B, the patient’s admission was handled by the neurosurgeon’s nurse practitioner. Hospital B was in the process of converting to a new electronic medical record (EMR). Upon the patient’s transfer to Hospital B, a floor nurse entered the patient’s medications into the EMR as interpreted from Hospital A’s record, including 400 mg of temozolamide daily. The nurse practitioner who admitted the patient dictated a history and physical that did not mention temozolamide, but he did complete a medication reconciliation form wherein he checked off to continue all medications, including temozolamide and signed the form. This order was not co-signed by the neurosurgeon.

The neurosurgeon saw the patient the next day. In the consultation note regarding medications, the neurosurgeon noted “see prior history.” The neurosurgeon also had not adapted to the new EMR system, and he did not review the list of medications. The neurosurgeon took the patient to surgery for a repeat left craniotomy and tumor resection three days after admission. An Order Reconciliation Form that ordered the continuation of all medications was signed by the neurosurgeon’s nurse practitioner postoperatively.

Six days following surgery, the patient was discharged from the hospital and transferred to an inpatient rehabilitation facility, with orders to continue all medications. The admitting physician at the rehabilitation facility signed the medication order as is, and continued the temozolamide.

After ten days in the rehabilitation facility, the patient was readmitted back to Hospital A under the care of his oncologist due to his declining condition. After completing diagnostic studies and reviewing the medical records from Hospital B and the rehabilitation facility, the oncologist discovered that the patient had received a massive overdose of temozolamide.

The patient remained hospitalized at Hospital A for more than four months with liver toxicity, pulmonary toxicity, bone marrow insufficiency, skin rash with scaling and sloughing, wound dehiscence leading to removal of cranial hardware, and a need for total parental nutrition.

Following discharge from Hospital A, the patient remained in rehabilitation and skilled nursing facilities until being transferred to hospice. The patient died eleven months after the initial admission to Hospital B.


Allegations
A lawsuit was filed against Hospital B, the nurse practitioner, the neurosurgeon, and the admitting physician for the rehabilitation facility. The allegations included:

  • ordering or authorizing an improper medication;
  • failure of the nurse practitioner to consult with a physician;
  • failure of the neurosurgeon to properly supervise a nurse practitioner; and
  • failure to be sufficiently knowledgeable about temozolamide before ordering it.
     

Legal implications
Although the patient had a fatal illness and did not have long to live, the purpose of undergoing the craniotomies was to improve his quality of life. The plaintiff’s expert stated that the craniotomies would have given the patient two more years to live. Instead, the patient lived only eleven months with a poor quality of life.

The defense was unable to find an expert who could support the care of any of the providers. The physician reviewers stated that it is within the standard of care for physicians to check the list of medications, regardless of involvement of a nurse practitioner. The neurosurgeon’s failure to do so made him vicariously liable for the nurse practitioner’s actions. The plaintiff indicated that the neurosurgeon’s exposure was limited but existent nonetheless.

The reviewers were also critical of the nurse practitioner for not consulting with the neurosurgeon, and felt he had an obligation to understand what medications he was ordering. If he was unaware of the medication temozolamide, further education was warranted.

The neurosurgeon remained adamant that he was not responsible for this error. He felt that the hospital was responsible for adapting an EMR that was too difficult to use, the pharmacy was responsible for not catching the error when dispensing the drugs, and the nurses who gave the medication were responsible for not questioning what they were giving the patient.
 

Disposition
At mediation, Hospital B settled on behalf of its nursing and pharmacy staff. Settlements were also made on behalf of the nurse practitioner and the neurosurgeon. The nurse practitioner was eventually disciplined by the Texas Board of Nursing. The outcome of the case against the admitting physician at the rehabilitation facility is unknown.
 

Risk management considerations
An employer may be vicariously liable for the negligence of its employee, as long as the employee was acting within the scope of employment. While it is common for a surgeon to rely on hospitalists and nurse practitioners for medication management, the attending physician is ultimately responsible for being aware of the medications prescribed.

It is imperative for physicians who employ mid-level providers to have a written scope of practice in the mid-level’s personnel file. In this case, prescribing temozolamide was out of this nurse practitioner’s scope of practice as the drug is typically used in oncology. Physicians should make sure that their mid-levels understand their duties and monitor to ensure guidelines are being followed.

It is recommended that medications are reviewed with the patient and documented at each encounter. Simply noting “see prior history” is inadequate documentation.

This case is a good example of one of the problems inherent in the use of an EMR. When inaccurate information is entered into the system, it is often copied from one encounter to the next without being updated or corrected. Physicians must remain vigilant in reviewing information that is entered into an EMR to make sure that it is accurate and that the information applies to the current encounter.

 

These closed claim studies are based on an actual malpractice claims from TMLT. These cases illustrates how action or inaction on the part of physicians led to allegations of professional liability, and how risk management techniques may have either prevented the outcome or increased the physician’s defensibility. These studies have been modified to protect the privacy of the physicians and patients.

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