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Upon reading the March, 2010 edition of Clinical Advisor, I encountered an article in their Newsline section. This article summarized a letter in Annals of Internal Medicine (2010;152:66-67. The article caught my interest for several reasons. It highlighted the concern for a potential sentinel reaction to a pediatric patient. In addition to this is a concern for patients of all ages but particularly the Geriatric patient who is on polypharmacy and can easily have a drug-drug reaction when prescribing OTC’s. As I examine this even more closely I observe a final focus on malpractice and the need for a “spoonful of security.”
It is in the purview of PAs in pediatrics, family practice, internal medicine, urgent care, emergency medicine, retail health care and geriatrics to examine their patients who present with symptoms of a cold, allergy symptoms or a cough, and the final disposition is the patient is supplied with a note suggesting some form of OTC medicine. We commonly use the phrase “one or two teaspoons” and either document or fail to document this dosage. Either way, the potential for creating an iatrogenic poisoning or a drug reaction is quite high. It is always important to know what medications your patient may be taking, a practice that should accompany every patient encounter as it will train the clinician’s mind to think with the same process that they would utilize with a new patient. Most PAs and NPs enter this profession with the idea of working for 30-40 years and prudent thinking in the prevention of malpractice can never start too early. This thoughtful practice will also illuminate cross sensitivity to the prescribed OTC drug. We need to look at OTC’s as carefully as we would any prescribed medication. It is equally important to know the age and the weight of your patient, as a spoonful may be too little or too much. If the patient is a pediatric patient; the parent may be confused by the description of a spoonful and give a tablespoon, a teaspoon or a pediatric feeding spoonful. Children who are taking a drug, particularly an OTC drug, have a greater possibility of having a reaction.
For many of our senior citizens on polypharmacy, there are many potential drug-drug-interactions that will increase or decrease the effectiveness of their other medications making way for hypertension, severe hypotension or rhythm changes related to their cardiac drugs. For a moment consider the patient on Coumadin which has restrictions of other medications as well as foods and alcohol which can greatly affect their INR and create a life threatening bleed in the brain or in the GI system. I was scolded by my Cardiologist last month for taking a class lll antiarhythmic with herbal drugs or vitamins and minerals. He made me wait an additional hour in his office, then had me step into his private room and asked me, ”What is it that you don’t you understand about taking no additional supplements or herbs?” As a HCP he was shocked at my actions as they can affect my drug to the degree that I could have Torsades De Pontes. He asked me if my need to take supplements, including fish oil and glucosamine and chondroitin, surpassed my need to live. His direct approach created an awareness of my nonchalant attitude with supplements.
All of these potential problems can lead to a poor outcome for the patient as well as a possible lawsuit. What can the collective “we” do to prevent a patient incident that is negative or life threatening? Check for other medications, review their current drugs, look at their age and weight and be slow to write for an OTC unless I am aware of the medications within the prescribed product. Is there anything else to glean from this? Perhaps the fact that failure to document the other medications and to cross reference contraindications and reactions are high on the hit list of causes for litigation involving PAs as well as NPs and particularly in the setting of the Retail Healthcare Clinic. These findings should ultimately cause the clinician to consider how to best protect themselves, their professional futures and their families from the sequel of litigation due to negligence. Is the insurance that our SP purchase for us enough for a situation as I have described? Will the insurance company reject the case because of some breach in understanding of their policy? Will they cover problems related to accidental poisonings by a HCP? I suggest a “spoonful of protection” that can never be too little or too much. This is the time to contact your AAPA or AANP endorsed Liability Insurance carrier and purchase a personal professional liability insurance policy as it is the perfect prescription for all your professional needs. It is not a coincidence that you are reading this today but a heartfelt concern of a colleague who wishes all PAs and NPs a long and successful career. The ultimate goal is to retire with pride, satisfaction and without the debt of a jury finding that goes beyond whatever policy your physicians or hospitals or employers have purchased for you. This is a personal responsibility and I implore you to be responsible to yourself and your families.
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 150 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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