How a series of errors led to recurrent hypoglycemia

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Case Reports

How a series of errors led to recurrent hypoglycemia

J Fam Pract. 2006 June;55(6):489-497

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References

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CORRESPONDENCE: Ranjit Singh, MA, MBBChir(Cantab.), MBA, Associate Director, Patient Safety Research Center, Department of Family Medicine, Clinical Center, Room 155, 462 Grider Street, Buffalo NY 14215. E-mail: rs10@buffalo.edu

Similarly, third-party payers such as many state Medicaid systems have the opportunity to identify and alert physicians to therapeutic duplications. However, I could find no reports in the literature regarding the implementation or effectiveness of such systems.

TABLE 2 offers suggestions for reducing the risk of therapeutic duplication in your practice.

FAST TRACK

Instead of fixing blame, we should fix the system that allowed the failure and the absence of safety protocols

Medication reconciliation is key. As a step toward addressing the larger picture of medication errors, the Joint Commission for Accreditation of Healthcare Organizations (JCAHO) has introduced for the year 2006 the following Patient Safety Goal (Goal #8): “Accurately and completely reconcile medications across the continuum of care,” commonly referred to as “medication reconciliation.”⁵ JCAHO’s adoption of this goal acknowledges, first, that transitions between different parts of the system are a common source of error, and, second, that these transition points (eg, admission to the hospital, or transfer out of the ICU) are opportunities to detect and correct errors. Various tools have been reported in the literature for addressing this issue. ^6-8 The strategies listed in TABLE 2 can also be seen as contributing to this JCAHO goal.

TABLE 1

Have you encountered these causes of therapeutic duplication?

MISCOMMUNICATION
In this case, the patient misunderstood the prescription to be for a new medication rather than a refill of an existing one. Miscommunications can be caused by the patient, the doctor, nursing staff, pharmacy staff, or any combination of these.
KNOWLEDGE DEFICIT
For example, a physician who does not know that sulindac is an NSAID might prescribe another NSAID such as ibuprofen to a patient whose pain is not controlled with sulindac.
POOR MEDICATION TRACKING WITHIN A PRACTICE
The office in this case relied on paper-based medication lists that were poorly maintained. The covering physician did not have access to accurate information about the most recent prescription date and number of refills, and elected to give a refill on Glucotrol XL. It is important to note that the primary physician might also have made the same mistake given the ineffective tracking system.
POOR MEDICATION TRACKING DURING TRANSITIONS
When patients move between different parts of the healthcare system such as the primary physician’s office, a specialist’s office, emergency departments, hospitals, and nursing homes, there are opportunities for errors, including therapeutic duplication. Transitions into and out of the hospital are receiving increasing attention because of the trend towards use of hospitalists.²⁵ Unless specific systems are put in place to ensure continuity (as exist in some integrated healthcare systems), hospitalists and residents who provide inpatient coverage often do not have immediate access to accurate information regarding a patient’s prior medications and refills.
FORMULARY ISSUES
The policies of some hospitals and health insurance carriers can lead to therapeutic substitutions that can in turn result in therapeutic duplication. For example, if a patient who takes ramipril at home for hypertension is changed to enalapril during hospitalization and is given a prescription for enalapril at discharge, he might take both.

TABLE 2

Strategies for preventing or detecting therapeutic duplication

Keep better medication records (preferably with an EMR). This includes keeping track of dosage changes, refill dates, and numbers of refills given. Consider including the indication for each drug so that it is easier to detect therapeutic duplication.
Communicate better with patients regarding medications, especially when changes are made. Ask patients to repeat your instructions to check their understanding.
Encourage patients to use the same pharmacy (or chain) consistently, explaining that the usual pharmacist will have much better access to their medication records.
For high-risk patients (such as cognitively impaired, those on multiple medications, those with multiple physicians), arrange for regular medication review, at which a patient brings all medications to the office.
If you use a hospitalist (or residency program) for inpatient coverage, ensure that you have adequate systems in place to provide continuity of care regarding medications and other issues.
At post-hospitalization follow-up visits, review medications carefully. You may detect a variety of errors.
Consider implementing patient-carried medication lists. These can be paper-based or electronic.

The story unfolds

You now know the patient has been taking twice the intended dose of his sulphonylurea for about a month, and you ask how he has been feeling during this time. He says he did well initially and did not experience any symptoms of hypoglycemia or hyperglycemia. He has a glucometer at home but did not use it during this period.

Two days ago, his wife expressed concerned that he was seeing several doctors (urologist, medical oncologist, radiation oncologist) for the prostate cancer and wanted to make sure he told them about all his medications. She asked him to make a list of his medications and to keep it in his wallet. He did so (FIGURE 1). That night he went out drinking (in his words, “the whole night”) because he was worried about his upcoming prostate surgery.