Transcript Errors in Transfer Orders

ERRORS IN TRANSFER ORDERS
Keith Lau, M.D.
Department of Pediatrics
McMaster University
October 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 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. 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-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
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 infection
 the 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
