This month’s case looks at the important issue of communication, and how good communication and asking the right questions can help protect you from errors and lawsuits. Primary care practitioners are busier than ever these days, and it is easy to have one’s attention divided. This case looks at the danger of not giving your patient 100% attention, and how taking the time to ask one simple question could have avoided the bad outcome for both the patient and the clinician.

Medical Case Facts

Dr. V, 61, was a family practitioner who had a small practice with three other physicians. He had been with the practice for over two decades, and had every intention of remaining there until his retirement. The physician had a loyal following of patients in his town. Because he had been practicing in the same place for so long, he was now even seeing the grown children of patients in some cases as well.

In recent years, he and his partners had been forced to see more patients in shorter periods of time. This sometimes led to a crowded waiting room and impatience.

Late one afternoon as Dr. V was getting ready to enter the exam room to see his last patient of the day, the office’s receptionist stopped him in the hallway to say that Ms. B was calling on behalf of her mother, Mrs. B. Both the mother and daughter were patients of Dr. V, but he saw the 52-year old mother far more often than her 30-year old daughter. The mother, Mrs. B, suffered from migraines. Over the past several years she had been prescribed various medications for migraine by Dr. V, most recently almotriptan, with mixed success.

The physician looked at the exam room door, knowing that a patient was waiting there. He looked at the receptionist with the phone in her hand.

“Did Ms. B say what the problem was?” he asked the receptionist.

“Yes, she said that her mother was having a migraine and was in a lot of pain and wanted to try something different and was hoping you could call in a prescription,” she replied.

Glancing once more at the door behind which his next patient was waiting, he reached for the phone. “I’ll speak to her,” he told the receptionist.

On the phone, Ms. B reiterated what she had told the receptionist. Her mother was suffering from a migraine, was in a lot of pain, was sensitive to light and sound and was queasy. She wanted to try a new treatment option.

“Okay,” said Dr. V, still eyeing the exam room door. “I will call the prescription in to your mother’s pharmacy. Will you be able to pick it up for her?”

The daughter agreed that she would pick up the medication.

“Please have your mother call us tomorrow,” said Dr. V, “to schedule an appointment to discuss more strategies for treating the migraines.”

The physician quickly called the pharmacy and ordered sumatriptan for Mrs. B. He noted the new medication in her file, and finally went into the exam room to see the last patient of the day.

The next day he didn’t hear from Mrs. B, but assumed she would call to make an appointment when she was feeling better. Unbeknownst to Dr. V, Mrs. B suffered a hemorrhagic stroke after taking the new medication prescribed by him.

At the hospital, the daughter explained that her mother had been suffering from a migraine and had taken almotriptan to treat it. When that didn’t work, she called Dr. V and got the new prescription. Then her mother had suffered a stroke.

“Did the prescribing physician know that your mother had already taken almotriptan when he called in a prescription for sumatriptan?” the hospital physician asked. 

“I don’t know,” said the daughter. “Dr. V never asked if my mom had taken anything else.”

Mrs. B was left with permanent left-side paralysis, requiring assistive devices, modifications to her home, and home health care. She and her daughter consulted with a plaintiff’s attorney who told them that Dr. V had been negligent in prescribing the new migraine medication without first asking whether Mrs. B had taken almotriptan recently, and without warning her that she should not take sumatriptan if she had taken almotriptan in the past 24 hours.

When Dr. V was informed that he was being sued, he immediately consulted with a defense attorney. The attorney asked whether he remembered questioning Ms. B about what her mother had taken before prescribing the new medication.

Dr. V looked downcast. “I honestly don’t know,” he admitted. “I got the call when I was headed into the exam room to see a patient. I was in a bit of a rush…”

The attorney suggested that they consider settlement negotiations, and Dr. V agreed.

Legal Background

Settlement negotiations began, but were unsuccessful and the case went to a jury trial. At trial, the plaintiff’s experts testified that Dr. V had breached the standard of care by not asking whether Mrs. B had taken any medication already, and by failing to warn the patient that she should not take two triptan medications within 24 hours of each other. Dr. V had no notes or records showing that he had warned the patient or asked her if she had taken anything else. Neither he, nor the receptionist, remembered him asking Mrs. B whether she had taken any medication prior to his prescribing sumatriptan. After a trial lasting a week, the jury found for the plaintiff and awarded her a little over $4 million.

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Protecting Yourself

It’s quite common for clinicians to be interrupted and pulled away from tasks during work. There are always emergency phone calls, patients that need immediate answers, scripts that need to be called in, and other interruptions. Unfortunately, these interruptions can lead to mistakes, or in this case, omissions.

Although Dr. V had prescribed migraine medication to the patient in the past, he simply assumed when her daughter called saying that she wanted a “new treatment option,” that she had not yet taken a medication. The assumption was wrong, and the ensuing tragedy could have been prevented by asking the simple question “has she taken anything yet?” Asking whether a patient has self-medicated before prescribing something else is always advisable.    

In this case, since Dr. V had already prescribed a triptan medication to this patient in the past, it was especially important to double check that she had not already taken one triptan when the physician intended to prescribe another. In addition, the patient should have been warned not to take other triptan medications within 24 hours of each other.

Even if you are busy, remind yourself that the patient you are talking to at the moment deserves 100% of your attention, even for the few brief moments you are on the phone. The unasked medical history question could end up costing both you, and your patient, a great deal.