Legal Pearls: Physician Faulted for Failing to Monitor Patient’s Medications

Blood-thinning medications prevent numerous strokes and deaths every year, but they are also some of the most challenging medications to manage. While patients failing to adhere to treatment regimens are often the problem, sometimes it is the fault of the healthcare provider when things go awry, as in this month’s case.

Clinical Scenario

The physician, a 52-year-old family practitioner who shared a practice with several other primary care physicians, saw a wide range of patients—from those just switching from a pediatrician to the geriatric. One of his patients was this woman, aged 76 years, who he had been caring for over the past decade. She was on long-term Coumadin therapy, and a few other maintenance medications, but was in otherwise fairly good health for her age.

One day, she tripped on a rug in her house and toppled down her stairs. Her husband called an ambulance and paramedics sped her to the emergency department of the local hospital. At the hospital, x-rays, scans, and bloodwork were ordered. She was diagnosed with a kidney laceration, broken ribs, and fractured vertebrae. She was admitted to the hospital and her Coumadin was stopped by the hospital physician.

The patient remained in the hospital for several days. The physician visited her there and spoke to the patient and her husband about her options. The hospital would only keep her a few days more, and her husband was unable to give her the level of care she would need during the recovery period. It was decided that she would be transferred to a nursing facility for a few weeks until she was able to return home.

The arrangements were made and after a few more days at the hospital, she was moved to the rehabilitation facility. The physician checked in with the facility when she was first moved there and went over the list of medications transferred from the hospital with the facility nurse and pharmacist. The list from the hospital did not include Coumadin, since that had been halted upon her admission, and the physician failed to notice its absence.

The physician returned to his busy practice but tried to call and check on the patient every few days. Two weeks after her move to the rehabilitation facility, she had a major stroke, resulting in her death. When the physician was notified, he was immediately shocked and saddened, but his shock changed to horror when he heard she had died from a stroke. Wasn’t she on Coumadin? He quickly looked at her records and then asked the facility to fax him her medication list. He soon realized that he had neglected to order that the Coumadin be started again after the hospitalization.

The Legal Case

The physician went to see the defense attorney assigned by his malpractice insurance and explained the situation. He was honest with the attorney because he knew that he had nothing to gain by misleading her.

“I screwed up,” the physician told the attorney. “This has never happened to me before. When the patient was hospitalized, her Coumadin was stopped. But when she was transferred to the nursing facility, it never got added back onto the list of medications. I actually did look at their list, but I was just verifying that everything on there was correct, not that something was missing. It didn’t occur to me that something might be missing.”

The attorney nodded and told him that she was going to have two physician experts go over the medical records and the scenario and see what they have to say. “Then we can decide if settling is the best option,” she said.

The physician wanted to settle and was relieved when the attorney eventually suggested that he do, after the reports from the expert physicians came back. The experts were highly critical of the physician's care of his patient. They felt his medication reconciliation at the time she was admitted to the nursing facility was shoddy, and that he should have also consulted his own records as well as the hospital’s medication list.

The two sides met for a settlement conference, where the physician's offer to settle the matter was accepted. The case was settled out of court for an unspecified sum.

The Takeaway

Monitoring and managing medication can be challenging, especially when a patient is moving across care settings–from hospital, to rehab, to home. Some medications may need to be stopped when a patient is hospitalized, and new medications may be ordered. Keeping track of what has been stopped, what has been added, and what will need to be restarted or stopped when a patient is released can be difficult.

In cases when a patient is being discharged from the hospital to home, transitioning care to a different facility, or has a change in medical status, it is essential to go over the patient’s medication list. Patients or their caregivers should be a part of this conversation. For example, in this case had the physician gone over the medication list with the patient or her husband, one of them might have asked about the Coumadin since she had been taking it for years. Don’t leave the patient out of the equation.

Bottom Line—All maintenance medications should be reviewed regularly, and always when a patient experiences new symptoms, begins an additional medication, receives a new diagnosis, undergoes an invasive procedure, or is hospitalized or discharged from the hospital

Ann W. Latner, JD, is a freelance writer and attorney based in New York. She was formerly the director of periodicals at the American Pharmacists Association and editor of Pharmacy Times.