PRESCRIBING: A DANGEROUS DOSE
BACKGROUND: Mr S, 68, has been seeking treatment for osteoarthritis for more than six years. In the
past two years the condition has worsened, causing considerable pain in his back and legs. During that time, his GP Dr B has prescribed 10mg morphine sulphate tablets (MST) – two pills to be taken twice daily. Mr S visits the practice for a repeat
prescription and the request is dealt with by Dr N who then handwrites out a prescription for 100mg MST, two tablets twice daily. Mr S fills the prescription at the pharmacy and proceeds to take two tablets before going to bed. He wakes up during the night feeling unwell and is violently sick the next morning. His wife calls for an ambulance but he is pronounced dead in his home a short time later. Several months later, a claim of clinical
negligence is lodged by Mrs S against Dr N, accusing him of causing or contributing to the death of her husband and seeking payment of damages. A claim is also lodged on the grounds of vicarious liability against Dr N’s two fellow GP practice partners, as well as against the pharmacist who failed to spot the dosage error. Dr N and his partners are MDDUS members and seek advice on how to proceed.
ANALYSIS/OUTCOME: MDDUS asks Dr N for his account of the events surrounding the repeat prescription issued to Mr S. He explains that he had been under considerable pressure in the practice that day and was struggling to work through a large number of patient requests for repeat prescriptions. He admits that, while the printed repeat prescription request was for the correct dosage, he made an error when copying the information by hand onto the prescription itself. He adds that he has also since apologised in a phone call to Mrs S.
MDDUS instructs an expert opinion from a
cardiologist regarding how Mr S died. Its findings are considered alongside the official cause of death which is stated as coronary artery disease but with the vomiting induced by the high dose of morphine acting as a contributing factor. Following discussions with Dr N, MDDUS
informs representatives of Mrs S that Dr N accepts liability in Mr S’s death but it is disputed that Dr N’s error caused Mr S’s death. After further lengthy legal discussions, MDDUS agrees a settlement with Mrs S for a sum of compensation, the cost of which is partly shared with the National Pharmacy Association, representatives of the pharmacist who dispensed the MST.
KEY POINTS
● Have a low threshold for double-checking prescriptions when dealing with high-risk drugs, particularly dosage calculations.
● Encourage a good level of knowledge and understanding of medicines in patients
with chronic conditions.
CONSENT: CRYOTHERAPY RISKS
BACKGROUND: Ms C is a diabetic and attends her GP, Dr N, complaining of pain in her right foot. Dr N examines the foot and diagnoses a plantar wart. He explains three different treatment options and the associated risks of infection and delayed healing due to her diabetes. He recommends liquid nitrogen treatment as he believes it to be the quickest and most efficient option and refers her to his colleague Dr E. Dr E administers liquid nitrogen treatment
on several occasions over a number of weeks but after the third application Ms C complains that the pain has returned. Dr E administers a final treatment of cryotherapy and refers Ms C to a podiatrist who diagnoses her with infection in her foot and prescribes a short course of antibiotics. At a follow-up appointment with the podiatrist two weeks later, the consultant identifies a deep cutaneous slough on Ms C’s right foot as a result of the repeated liquid nitrogen treatment and a foot ulcer. The ulcer worsens and eventually requires her to be admitted to hospital for treatment of the
SUMMER 2012
infection. Ms C’s foot does not heal for another 10 weeks and causes her considerable pain when standing or walking. Once the infection clears, she is left with a residual area of impaired sensation on her right foot. Ms C files a claim of clinical negligence against Dr E alleging that he treated her without explaining the risks. While Dr N is a member of MDDUS, Dr E is represented by another indemnity organisation.
ANALYSIS/OUTCOME: Representatives of Dr E contact MDDUS to query the role of Dr N in the initial consultation and referral of Ms C. They question whether Dr N gave Ms C appropriate advice and whether he sufficiently explained all the available treatment options and their associated risks.
An MDDUS medico-legal adviser contacts Dr N asking him for an account of his involvement in the case and, in the absence of a detailed medical note, what his normal practice would be in such consultations. Dr N confirms that his normal practice would have been to carefully explain the associated risks
of all three treatment options, taking into consideration Ms C’s diabetes. MDDUS informs Dr E’s representatives of
Dr N’s position and confirms that he will have no further involvement in the claim.
KEY POINTS
● Clearly explain treatment options and associated risks, taking into account existing conditions such as diabetes, when referring patients.
● Ensure patients referred to you for treatment understand treatment and
associated risks before carrying out the procedure.
● Take clear, comprehensive notes of patient discussions and agreed
treatment plan. 21
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24