This month we look at how one medication error, which could have been identified numerous times, went unnoticed until it was too late.

Dr. P, 42, was a nephrologist who had a private practice in a large medical arts building. Many of his patients were referrals from other physicians who worked in the building. One such referral was Mr. W, 50. The patient had been referred to Dr. P for renal insufficiency. Mr. W had a history of ankylosing spondylitis and scleroderma. He had an elevated serum creatinine, low creatinine clearance, anemia, and proteinuria. He had previously been prescribed 5mg of prednisone daily for treatment of his renal disease.

After the physician examined the patient and went over the lab work, he felt there was no evidence of acute sclerodermal crisis that would account for Mr. W’s kidney failure. Dr. P decided to put the patient on an ACE inhibitor and see if that improved the situation.

After ten weeks, and two more office visits, Mr. W’s creatinine failed to improve and proteinuria was still significant. Dr. P continued to monitor the patient for several more weeks. In the meantime, he increased the daily prednisone dose to 10mg.


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Unfortunately, the patient’s kidney function was not improving. At their next appointment, Dr. P discussed with Mr. W the possibility that kidney dialysis would be necessary. The patient became very agitated and told the physician that he did not want to go on dialysis because he believed it would interfere with his ability to work. Dr. P agreed to try to avoid dialysis, but warned the patient that it might become necessary.

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At the next appointment, with the patient’s kidney function continuing to deteriorate, the doctor decided to put the patient on 120mg of prednisone every other day to see if renal function would improve. He sent an email to his nurse, Ms. N, stating “Kidney function is slightly worse. As a last-ditch effort to keep him off dialysis we need to have him take prednisone 120mg every other day.” Then Dr. P left for a much needed 10-day vacation.

The next day, Ms. N called in the prescription to the pharmacy, but mistakenly ordered 120mg of prednisone every day rather than every other day. She then completed the medication summary in the patient’s chart to reflect 120mg daily.

The prescription was flagged by the pharmacy’s computer because the dosage was too high, and a pharmacist called and spoke to Ms. N who confirmed the dosage by looking at the medication summary in the chart rather than the original order from the physician. Mr. W’s wife also called Ms. N to question the dose, but was told by the nurse that it was fine.

When the physician returned from vacation, he signed off on several emails (including a copy of the prescription with the 120mg/day dose) without opening them – but simply by checking a “signature box.” He then deleted the prescription from his email list.

Nine days after Mr. W began taking the daily 120mg of prednisone, he came in to see Ms. N for his Procrit injection. He complained to the nurse about tremors, esophageal burning, hiccups, stomach pain, and swallowing problems. Ms. N told the patient that she would let the physician know. After the patient left, she emailed Dr. P. However, the physician never saw this email and it was likely deleted as the other emails had been.

Another eight days passed and Mr. W called Dr. P complaining that he was not feeling well. (The physician was still unaware of the prescription error). Dr. P advised him to drop the prednisone back to 10mg a day. An appointment was scheduled the next day.

When the patient came into the office the next day, he had extremely low blood pressure, elevated heart rate, and was going into shock. He was admitted to a local hospital where he was diagnosed with severe dehydration, gastrointestinal bleeding, and symptoms of sepsis. Despite aggressive treatment, Mr. W died two days later.

A few months later, Dr. P was notified that he was being sued by Mr. W’s widow. The allegations included prescribing too high a dose of prednisone, failing to properly monitor the patient, and failing to properly supervise staff in placing an order of prednisone. Dr. P consulted with the defense attorney provided by his malpractice insurance.

Legal Background

The defense attorney and the plaintiff’s attorney both hired medical experts to review the case. The plaintiff’s attorney found experts who were critical of Dr. P’s decision to initiate steroid therapy, however the defense experts all agreed that the physician’s decision to put the patient on alternate-day high-dose steroids was well reasoned and made sense.

However, the defense experts expressed great concern about Dr. P’s sign off on the emailed prescription. The physician tried to explain it to the attorney. “The way that I pulled up the email, the actual prescription information didn’t show… so I didn’t actually see the text,” he explained.

“But by clicking on the signature box you were effectively signing off on the prescription,” said the attorney. “This is problematic to defend. Signing off on a prescription order that you didn’t review would likely be considered by a jury to be below the standard of care owed to your patient.”

After careful consideration, the case was settled out of court for an amount within Dr. P’s insurance coverage.

Protecting Yourself

Several mistakes were made in this situation. Ms. N made the first mistake by accidentally ordering the prednisone on a daily rather than every other day basis. There were two opportunities for her to remedy this error – one when the pharmacist called, and one when the patient’s wife called. However, Ms. N did not recheck the original medication order from the physician, and instead just looked at her own notes. She had two opportunities to notice that the prescription was incorrect, but she failed to do so.

A third chance to intervene and stop the daily dose was still possible when Dr. P was reviewing his emails, but he clicked on the signature without actually reviewing the prescription. A physician cannot defend his or her actions if established standards are not followed. Signing off on an unread order is below the standard of care.

Electronically signing an order is an affirmation that it is correct.  Never sign a prescription order – by hand, electronically, or by clicking a box – unless you have verified that the prescription is, in fact, correct.