ERRORS IN TRANSFER ORDERS

Keith Lau, M.D.Department of PediatricsMcMaster UniversityOctober 15, 2009

SETTING

A 75-year-old lady developed a methicillin-resistant Staphylococcus aureus (MRSA) in the hospital following knee replacement surgery

Ccreatinine test that showed her kidneys were functioning normally

After weighing the potential for harm from the infection and potential side effects from the medication

SETTING

Decided to include gentamicin, together with vancomycin and rifampicin, in her treatment regimen

The course of gentamicin was to be very short

Was to be discontinued prior to her transfer to a nursing home

Discharge antibiotics would be IV vancomycin and oral rifampicin

DISCHARGE ORDERS MIXED UP

SETTING

Attending physician was on vacation when the patient was transferred to the nursing home

The nurse contacted the physician’s partner over the phone for the orders

Then, the nurse drafted a Patient Transfer Form that accompanied the patient to the nursing home

SETTING

Contrary to the attending physician’s initial plan

Gentamicin was included in the list of medications

“gentamicin 120 mg IV piggybag every 12 hours, next dose, 9 pm today, 6/10”

SETTING

At the nursing home, the patient continued to receive IV gentamicin

On day 3 after the transfer, the patient had trouble in urinating

Creatinine was checked and was abnormally high

SETTING

Creatinine was repeated Gentamicin was not discontinue The result came back the next day,

and was even higher and then Gentamicin was then stopped Patient suffered from acute renal

failure that required acute hemodialysis

CASE

Plaintiff: Lady A Defendants:

Hospital B Dr. C (ID specialist) Nursing Home D Dr. E (ID specialist) Nurse F (nurse of Hospital B) Dr. G (staff physician at Nursing Home D)

NURSE F(EMPLOYEE OF HOSPITAL A WHO DRAFTED THE TRANSFER FORM)

Testified that: she drafted the transfer order (including the

gentamicin) She spoke to Dr. E on the phone for the orders

before lady A was transferred Dr. E was contacted because Dr. C was on

vacation

NURSE F

could not remember the particular conversation with Dr. E

custom and practice would have been for Dr. E to ask her for the information contained in the chart

she would have written the order exactly as Dr. E gave to her and

would have read it back to him for verification

NURSE G (PLAINTIFF’S NURSING EXPERT)NURSE H (DIRECTOR OF NURSING OF NURSING HOME D)

testified that:Expect a reasonably well-qualified nurse to

know that gentamicin is nephrotoxicNurse F deviated from the standard of care

by listing gentamicin on the order because Dr. C did not call for it

If Nurse F told Dr. E that Dr. C’s plan called for plaintiff to be placed on gentamicin, it was also a deviation from the standard

NURSE G (PLAINTIFF’S NURSING EXPERT)NURSE H (DIRECTOR OF NURSING OF NURSING HOME D)

Transfer form provides a “continuity of care”

Never seen a medication listed on transfer form that had been discontinued before the transfer

NURSE I (NURSE AT NURSING HOME D)

testified that: Relied on the medication list on the transfer form

to prepare her own physician order form for the plaintiff

Based on the transfer form, she believed that the plaintiff was to receive gentamicin

DR. E(GAVE THE TRANSFER ORDER OVER THE PHONE)

Testified that:He could not specifically recall the

conversation with Nurse F It was his custom and practice to have the

nurse convey to him over the phone the plan put in the chart by his partner

Wanted to follow his partner’s plan

DR. E

Would only have ordered gentamicin if he had been told the it was part of the plan

Must have been mis-informedAgree that Nursing Home D was

dependent on getting the accurate information from Hospital B as to what care the plaintiff should get after the transfer

Based on how the transfer form was written, he would expect the staff at Nursing Home to continue the gentamicin

DR. J (ATTENDING PHYSICIAN AT NURSING HOME D)

Testified: Transfer form is “to give the doctor in the nursing

home a guidance how to continue treating the patients”

Up to him to determine whether to follow or not The orders appeared reasonable Decided to leave the medications as is

DR. J

He was questioned on: Why he did not check blood tests for kidney

functions for 2 days Why he did not discontinue the gentamicin after

the creatinine came back to be abnormally high

DR. J

Testified:Nursing Home did not check daily labs for

kidney functions unless the patient had some known past history of kidney problems

On a.m. of June 13, he was informed about plaintiff had trouble in urinating

Did not stop the gentamicin at that time Concern about infectionthe MRSA infection might cause the

plaintiff to lose a limb or her life

DR.K(PLAINTIFF’S KIDNEY SPECIALIST)

Testified that: As a result of the prolonged treatment of

gentamicin The plaintiff suffered permanent kidney failure Would require dialysis for the rest of her life

PROGRESS

Plaintiff’s MRSA infection resolved favorably and she returned to live at home

But now has permanent renal failure and required chronic hemodialysis 3 times weekly for the remainder of her life

CONCLUSIONS

No question about the negligence of the hospital nurse who did the paperwork for the transfer

She misread the chart and failed to see that the gentamicin had been discontinued

VERDICT

The only defendant found liable: Hospital B based on Nurse F’s “negligently informing Dr. E

that the long-term antibiotic plan from Dr. C was to include gentamicin”

Dr. J was not liable Jury awarded plaintiff $3,200,000

TAKE HOME MESSAGE

It is a challenge but important to ensure medicine reconciliation

Patient transition points are especially vulnerable to medication errors

Take extra time to review the list and if in doubt, ask

Simple solution can go a long way to decrease medication errors