At what point, we have to ask ourselves, does a medical error that we do over and over again cease to be an error, and simply become business as usual?

At one of the patient safety conferences this week, where we reviewed sentinel events that occurred in the hospital and in the outpatient setting, one of the cases was about a patient who developed an abnormal cardiac rhythm as a result of drug interactions between several medicines he was taking, some prescribed in our practice, some from other providers.

The root cause analysis revealed multiple issues, several challenges, and eye-opening problems with how we are providing care, including the fact that a known drug-drug interaction did not set off an alert within the electronic health record, and a medication was listed for the patient as “no longer taking” although it turned out he was in fact still taking it.

Multiple providers through years of taking care of this patient had clicked the “medication reconciliation” button, testifying to the fact they had gone over the patient’s medicines and this list was, to the best of their knowledge, accurate.

Despite the fact that the medication list was not in fact accurate, one of the medicines on his list was one that was refilled by our practice, but it turns out we really should not have been prescribing, and never really intended to prescribe, for the long-term management of this patient.

Looking back through years and years of this patient’s chart, the resident performing the root cause analysis found dozens and dozens of refills for this medicine, for which there was no plan of ongoing care documented in the patient’s chart.

This resident’s detective work ultimately revealed that this patient had received an initial prescription for this medicine (a medicine not usually prescribed by primary care doctors), over 10 years ago, before we even started using our current electronic health record.

Bridging a gap

The documentation of that original prescription showed that the patient had been receiving this medicine from another provider, and had recently terminated his relationship with that subspecialist, and requested a single bridging prescription of this medicine until he could establish care with a new appropriate prescriber of this medicine.

This was a well-documented, one-time, 30 day supply with no refills.

But then something happened, and then it happened over and over again.

This patient called up and requested a refill of a medication he was prescribed by us, and this other medicine as well, and at one point someone simply clicked the refill button, and sent all the medicines in.

From that time forward, every time this patient requested refills, the covering providers reviewing medication requests did what seemed like what a fairly thoughtful part of the refill process.

They looked back to what happened the last time this patient asked for this medicine.

And what did they find?

We gave it to him.

So in addition to his high blood pressure medicines, he continued getting this specialized medicine, for which we were not providing care.

Over and over through the years, we were refilling this medicine, without any real documentation in the chart of what it was indicated for, or that we were managing the condition for which he was supposedly taking it for.

The resident reviewing the case was able to find one mention in the chart that the patient had requested this medicine to use as a sleeping pill, which is certainly not what it is used for.

Establish refill boundaries

Most primary care providers are comfortable refilling medicines for conditions they are managing, that is, if I’m the one managing your high blood pressure, your diabetes, your asthma, your reflux, then I should be the one refilling those medicines.

If you’re getting specialized care from a subspecialist, and they’re chronically managing that problem, then they should be the one refilling those medicines, monitoring you for its appropriate use, side effects, lab monitoring.

There are certainly exceptions, and we will do bridging prescriptions when someone can’t reach a specialist under certain circumstances, but this should be the exception, and never become the rule.

For every medicine we prescribe, our medical record should reflect the fact that we are managing this medical condition, that we are aware of all the medicines the patient is taking, that the use is appropriate, and that we think it’s a good idea for this patient to have ongoing access to this medicine.

Unfortunately, in this particular case, there was nothing in the chart about what this medicine was being used for, just a bunch of refills.

When the resident looking into this case talked to a number of the providers who were involved in the care of this patient, and those in the covering teams doing the refills, they felt that they had tried to do their best, to do due diligence, that it always seemed like the right thing to do to refill this medicine the patient was requesting.

The medicine was on the patient’s medication list, and it had been marked as reconciled at multiple visits, had been refilled multiple times, but no one bothered to dig in a little deeper, to say wait a minute, why am I prescribing this medicine today, is this for a condition that this patient’s primary care doctor is managing, and does the medical chart reflect this, anywhere?

A review all the way back through the chart, a very detailed review, did not reveal that the patient was getting treated by us, or by anyone else, for the medical conditions for which this medicine was indicated. And if, in fact, the patient was using it as a sleeping pill, as was noted in the initial prescription request, well, it’s not a sleeping pill.

Finding a solution

So how do we make this right? How do we make sure that we do not just do what a patient wants, but do what is right for a patient?

Everyone is rushed and overwhelmed, asked to refill medicines, to put in orders for labs for patient they don’t know, to order a scan on someone they’ve never seen before. When you build a large complex practice around a large complex group of patients, with a large group of providers, things get really complicated and scary and tricky very quickly.

It shouldn’t take an adverse event, a combination cocktail of pills that leads to an abnormal cardiac rhythm with significant symptoms, to make us figure out that a patient is not on the right medicines, that we’re doing some harm, or even potentially doing harm.

We need to build back the systems that let these things happen in a more calm, measured, and thoughtful way, so that we all have time to really think about patients, think about the click of the button we are making, before we reflexively just react.

Interim care and discontinuous care, care provided for certain problems that overwhelm the providers trying to take care of them, and lack of time and lack of other team members helping manage these complex patients, lead to people simply passing issues along. His medication list seemed okay, the patient seems to be doing fine, it was okay the last time we refilled this medicine, and so shouldn’t we just continue to do so?

We need to change the way this happens, because we are prescribing so many medicines, the chart is full of so many tiny little things that, when the stars align, can certainly lead to badness.

We all need the time, the space, the breathing room, and the support, to be able to look at each patient as a whole, to truly focus on them, to make sure that clicking that refill is really the right thing to do for them.

Making sure that things aren’t done in a rush, that we really have the time to focus on our patients, probably would’ve allowed someone to say to this patient, wait, what are you taking this medicine for, it looks like you’ve been taking it for years, who’s managing this condition, am I?

We have done right by this patient since this event. We have cleaned up his medication list, gotten them to an appropriate provider to help manage the condition for which this medicine was originally prescribed, and labeled his chart to reflect the fact that he should no longer be prescribed this medicine.

We are working with IT to try to improve the drug-drug interactions algorithm so that this kind of thing might be caught more easily, and hoping to develop a new way of labeling medicines such that it is clear who is responsible for prescribing a medicine, to prevent someone from inadvertently giving patients a medicine they’re not managing.

Putting that patient first, making sure they got the right care at the right time, would hopefully have prevented this adverse event from happening. Think of all the enumerable near misses waiting to happen, buried within the complex electronic record we are all striving to navigate.

Building a kinder, gentler, patient-centered team can move us towards a better health care world, where we are more likely to catch these errors waiting to happen, where we are more likely to prevent harm to our patients, or we are more likely to do right by them.

Fred N. Pelzman is an associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs at MedPage Today’s Building the Patient-Centered Medical Home.

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