Errors in Transfer Orders

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Errors in Transfer Orders

• Keith Lau, M.D.
• Department of Pediatrics
• McMaster University
• October 15, 2009

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(No Transcript)
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Setting

• A 75-year-old lady developed a methicillin-resista
  nt 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

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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

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Discharge orders mixed up
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Setting

• Attending physician was on vacation when the
  patient was transferred to the nursing home
• The nurse contacted the physicians partner over
  the phone for the orders
• Then, the nurse drafted a Patient Transfer Form
  that accompanied the patient to the nursing home

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Setting

• Contrary to the attending physicians 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

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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

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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

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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)

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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

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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

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Nurse G (plaintiffs nursing
expert)Nurse H (Director of nursing of Nursing
Home D)

• testified that
• Expect a reasonably well-qualified nurse to know
  that gentamicin is nephrotoxic
• Nurse 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. Cs plan called
  for plaintiff to be placed on gentamicin, it was
  also a deviation from the standard

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Nurse G (plaintiffs 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

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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

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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 partners plan

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Dr. E

• Would only have ordered gentamicin if he had been
  told the it was part of the plan
• Must have been mis-informed
• Agree 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

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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

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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

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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 infection
• the MRSA infection might cause the plaintiff to
  lose a limb or her life

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Dr.K(Plaintiffs 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

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Progress

• Plaintiffs 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

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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

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Verdict

• The only defendant found liable
• Hospital B
• based on Nurse Fs 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

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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