On The Docket
David B. Brushwood, BSPharm, JD
Arecent case from Illinois demonstrates, once again, how the instructions “as directed” in prescription vial labeling can invite malpractice liability.
Background
A 99-year-old patient had been using warfarin 1 mg for several years to treat AFib. She had taken one tablet daily for 6 days each week, and 1.5 tablets on one day each week.
The patient’s daughter, who is a registered nurse, helped her mother with medication management.
When a refill of warfarin was necessary, the physician electronically transmitted to the patient’s pharmacy a new order for 90 tablets of 3 mg warfarin. The pharmacy accurately processed and labeled it with “Take one tablet by mouth as directed.”
The daughter noticed that the tablets were a different color than usual, and she called the pharmacy. The daughter testified that she was told “if it’s a generic, they sometimes have a different manufacturer, so it might look a bit different.”
The patient took the 3 mg warfarin according to the previous schedule. The patient died, allegedly as the result of a threefold warfarin overdose.
The physician initially expressed surprise that the patient had been using 3 mg tablets. He explained to the family that “it wasn’t us” and that “the pharmacy made an error.”
It was later established that the physician’s electronic order was for 3 mg tablets. The physician then clarified that his custom was to order medication by milligrams and not by tablets and that his intended directions were to continue with 1 mg daily for 6 days and with 1.5 mg for the seventh day. He explained that the 90 warfarin 3 mg tablets were provided for use only on the seventh day when a half tablet would be taken. He explained that he relied on the patient’s daughter, as a nurse, to understand this without the need for explicit instruction.
Despite this explanation, a jury found the physician liable for $1.4 million. The physician filed a motion to set aside the jury verdict. As grounds for this motion, the physician argued that the judge had erred by not allowing his lawyers to explain to the jury that the daughter was a nurse and that the physician had relied on the daughter’s nursing expertise to protect her mother from a warfarin overdose.
The trial court denied this motion, and the physician appealed that ruling.
Rationale
The appellate court first noted its agreement with the trial judge that in managing her mother’s medications, the daughter was acting in a familial role and not in a professional role. The defense had not offered any expert testimony regarding a nurse’s professional standard of care.
The court explained that reference to the daughter’s nursing background “could be both confusing to the jury as well as unduly prejudicial.” It could have shifted the jury’s focus away from the physician’s responsibilities and toward the daughter’s responsibilities, which were not at issue in the lawsuit.
The appeal was denied. The jury verdict was affirmed.
Takeaways
The ruling in this case stands for the principle that even when patients or family members are health professionals, they must be cared for in the same way as those who lack education and training in the health professions.
Of significant interest in this case is a quote that the court provided from the pharmacist who processed the erroneously prescribed warfarin order. That pharmacist is quoted as having said that “her only role in filling the prescription was to verify that what was in the bottle was what was labeled on the bottle.”
What a missed opportunity!
Had the pharmacist accepted a broader role, the prescribing error could have been corrected. Pharmacist consultation with prescribers regarding unusual dose escalations, and with patients regarding changes in medication appearance, can prevent medication errors and reduce exposure to malpractice liability.
Pharmacists are front-line risk managers. They can identify potential risks, and they can prevent lawsuits. ■