Errors in Transfer Orders

1. Errors in Transfer Orders Keith Lau, M.D. Department of Pediatrics McMaster University October 15, 2009

3. 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

4. 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

5. Discharge orders mixed up

6. 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

7. 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”

8. 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

9. 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

10. 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)

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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