On The Docket
David B. Brushwood, BSPharm, JD
Unclear or incomplete prescription orders can set up pharmacists to err in order processing. Pharmacists may be held liable for malpractice when an order is misinterpreted. A recent case from Illinois serves as an example of such a situation.
Background
An 8-month-old patient was discharged from a hospital with a prescription that allegedly read:
“enoxaparin (LOVENOX) 30 MG/0.3 mL SC injection
inject 0.125 mL beneath the skin every 12 hours.
Quantity: **90 (Ninety) Syringe**
Refills: **0 (Zero)**”
The prescription was taken to a community pharmacy where the pharmacist allegedly dispensed 90 “single-dose, spring-loaded syringes, prefilled with 0.3 mL of Lovenox.” According to the court, “the prefilled syringes were made from clear transparent material and did not come with any demarcations, level, amount, or numerical measurement.” Using these syringes, the patient was administered multiple doses of enoxaparin at higher than the intended dosage. The patient died, allegedly due to “bleeding from the brain, that was caused by complications from the uncontrolled bleeding caused by the administration of a higher dosage of enoxaparin than prescribed.”
A malpractice lawsuit was filed against the pharmacy, alleging that “it should have been obvious to a competent pharmacist that Lovenox should not have been dispensed in single-use, spring-loaded syringes, but instead it should have been dispensed in multi-use syringes with proper dosage demarcations.”
The defendant pharmacy moved the court to dismiss the case. The pharmacy argued that “a pharmacy is not required to convey warnings to its customers about the adverse effects of a medication or its dosage.” The trial court dismissed the lawsuit and the plaintiff appealed.
Rationale
The appellate court reviewed a long history of Illinois pharmacist malpractice cases. Those cases recognize that pharmacists have no duty to warn a patient that an “excessive dosage” of medication has been prescribed for the patient. The rationale for these cases is that prescribers, not pharmacists, are responsible for drug dosing, except when a pharmacist has “knowledge of a dangerous condition” and the pharmacist “knows or should know that harm might or could occur if no warning is given.”
The appellate court disagreed with the pharmacy’s characterization of the lawsuit as a “duty to warn” lawsuit, and with the trial court’s acceptance of that characterization. The appellate court concluded that the “no duty to warn” argument “has no application here, where the negligence claim against [the pharmacy] was for failing to fill a prescription in a manner that could be safely administered in the amount as prescribed.”
Dismissal of the lawsuit against the pharmacy was reversed. The case will continue until it is resolved through a settlement or a judgment.
Discussion
There are several important risk management lessons to learn from this case.
- If there is any question whatsoever about the appropriate product to dispense pursuant to a prescription or order, the prescriber should be contacted for clarification.
- Any medication can cause adverse effects, but some medications (such as anticoagulants) can be considered high risk. Special care should be taken when dispensing high-risk medications.
- Prescriptions for particularly vulnerable patients such as infants, frail older adults, and those who are critically ill should be given special attention.
- Patients and family caregivers should be taught how to administer injectable medications. There may be a video available online that can be used to help explain injection technique. The person who will be administering a drug through injection should be asked to demonstrate how this will be done.
- The transition of a patient from institutional care to community care should be evaluated for potential communication deficiencies. Established protocols within an institution may be unknown in the community setting, leading to order interpretation errors that harm patients.
The increasing complexity of drug therapy is creating new opportunities for pharmacy practice, as well as new challenges for pharmacy risk management. Pharmacists must adapt to evolving drug therapies by involving themselves in patient care. ■