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| Know your medications before you prescribe or pick up orders. |
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by Bob Blumm, MA, PA-C, DFAAPA - February 13, 2012
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It was during my casual reading this month that I came upon an article in Clinician Reviews that was authored by a friend, Julia Pallentino, MSN, JD, ARNP and a colleague, David A. Lang, JD, PA-C. This article revealed a symphony of errors that was perpetuated until it ultimately caused the death of a 21 year old NC young woman, caused a family to grieve and had a plaintiff settlement of $15.5 million dollars. How could a tragedy such as I described happen? Is it possible that it can happen to the average PA? What can we do personally to prevent such a cascade of errors? All of these can be addressed in this short article.
Summarizing this patient and her progressive morbidity and mortality, this was a young woman who took what she assumed to be a harmless drug, OTC Acetaminophen. Most health care providers are aware of liver toxicity with this drug and maximize the dosage at 4,000 mg per day. The danger for patients is that they do not always read the labels and think nothing of taking additional pills for pain, sort of like topping off the gas tank. She later realized her error, went to the ER believing that she was now safe and experienced tragic errors due to judgment, inexperience and lack of following protocols. Unfortunately, two physicians, a number of RNs and a pharmacist as well as the hospital were all made to share the liability and all were found guilty. The defendants could easily have been a PA or NP as treating poisoning is part of our job description.
What are the lessons to be learned from this scenario? When there is a suspected overdose call the poison control center. Secure a name, write the treatment and read it back to the provider who supplied the information. Unfamiliar with the drug? Place a phone call directly to the pharmacist and speak with this individual personally. Make sure the dosage is written in a manner that can be easily understood by any health care provider. When or if you are transferring the patients make sure that the receiving unit understands the therapeutic care. If there is a physician in charge of the ICU than make sure you speak to them personally and discuss whether they have used this therapy before and when should the drug be discontinued. Never assume that the prescription from the referring physician or health care provider is correct, if you are unsure, check this carefully as if you were the primary provider in this case. If an error has been discovered, report it immediately and let the Quality Assurance department and chief of service become aware and involved. Never change an order or as in this case give a significantly lower dose to hide your error.
As a PA or other health care provider, you are going to make errors in judgment, and medication errors usually top the list for many reasons. It is for this reason that it is incumbent that the provider should be diligent to protect her/him and their future as well as their family by securing the best insurance to protect them and cover their involvement, particularly when a case involving the institution and a number of individuals are concerned. The only protection that can give you a sense of security is a Personal Liability Insurance Policy that specifically names you as the owner. This is of urgent importance for all clinicians. It is also a great idea to carry a good handbook that will have an overview of your patient situation and will give guidance as to what tests should be ordered and what treatment given.
Robert M. Blumm has received national recognition as a distinguished fellow of the American Academy of Physician Assistants (AAPA). He is the past president of the Association of Plastic Surgery Physician Assistants, and was past-president of the American Association of Surgical Physician Assistants, past president of the American College of Clinicians and NYSSPA, as well as Chairman of the Surgical Congress of the AAPA. In addition, Bob received the John Kirklin MD Award for Professional Excellence from the American Association of Surgical Physician Assistants. Along with his associate, Dr. Acker, Bob was the first recipient of the AAPA PAragon Physician-PA Partnership Award. He has been a contributing author of three textbooks, written 300 plus articles and is a sought out conference speaker throughout the United States.
The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.
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