Preventing medication mistakes

Prescription errors pose significant risks to patients, including adverse drug reactions, treatment interruptions, and potentially life-threatening situations. Dr Mohamed Faruqi Uzair Mohamed Sidek, Medicolegal Consultant at Medical Protection, and Ioanna Mavrovounioti, Case Manager at Medical Protection, discuss two cases where complaints were made to the Medical Council after the patient developed drug allergies.

Case study 1

A specialist in dermatology was consulted by a patient diagnosed with alopecia totalis, an autoimmune folliculitis. The treatment involved the admission of the patient as the tug test was positive, and the prescription of medications, including immunomodulatory agents, to manage the patient’s alopecia totalis. The patient complained of sore gums and dry eyes following treatment (suspected to be due to cyclosporine and tofacitinib). The doctor immediately instructed her to stop cyclosporine but it was later found out that the patient did not follow the doctor’s advice. The doctor closely monitored the patient and adjusted the treatment as needed, and ultimately, achieved positive results.

However, a complaint from the patient was lodged with the Malaysian Medical Council (MMC) in which the patient alleged that the doctor’s prescribed medication was inappropriate and resulted in several side effects, and the doctor benefitted financially from the treatment.

The doctor provided to the MMC a summary of his treatment, which included the prescription of medication and the patient’s progress during her admission to the hospital. He categorically denied the allegations made by the complainant.

Regarding the medication prescribed for alopecia totalis, the doctor defended his choice, stating that it was based on current evidence-based data. He referenced medical journals to support his decision and claimed that the prescribed medication represented the latest approach to managing the condition. He also mentioned that he monitored and adjusted the medication based on the patient’s symptoms.

The doctor denied allegations of financial gain, stating that he informed the patient about the insurance coverage of her medical bills. He provided details of the medical bills and payments made by the patient to refute the claim of financial enrichment. He also clarified that he does not profit from the medication prescribed to patients but receives consultation fees for his services at the hospital.

With the help from Medical Protection the doctor’s response refuted the allegations made by the complainant, emphasizing the evidence-based nature of his treatment decisions and providing financial details to demonstrate that he did not financially benefit from the patient’s treatment.

After reviewing the evidence, the MMC decided to dismiss the complaint.

Case study 2

A patient initially visited the general practitioner with complaints of foot pain, and after examination, they were diagnosed with cellulitis. Notably, the patient did not disclose any pre-existing drug allergies. The doctor prescribed a course of antibiotics for a 5-day duration.

After this initial treatment period, the patient returned to the doctor, revealing a new allergy to ceftibuten, which was the antibiotic they were actively taking. In response, the doctor and patient engaged in a discussion regarding whether to continue the antibiotic treatment. This decision was based on the patient’s apparent lack of adverse reactions to the medication thus far, and the observed improvement in their condition. Ultimately, the patient agreed to proceed with the same antibiotic treatment.

One month later, the patient revisited the doctor, and they were then diagnosed with suspected erythema nodosum. In response to this diagnosis, the doctor altered the patient’s medication and introduced steroids as part of the treatment plan. However, 3 days following this change, the patient developed a severe rash affecting their entire body, including the face, scalp, and legs. The patient was promptly referred to a hospital for further evaluation.

Subsequently, the patient filed a complaint with the MMC, alleging that the doctor had mistakenly prescribed cephalosporins, despite the patient’s known allergy to ceftibuten. The patient claimed that this prescription caused them to experience an allergic reaction affecting their entire body.

The central issue in this case revolves around the appropriateness and safety of the cephalexin prescription. After consulting with Medical Protection and the appointed legal representative, the doctor decided to provide a written explanation. In this statement, the doctor briefly clarified that they were only informed of the patient’s allergy to ceftibuten during the second consultation. If they had been aware of this allergy earlier, they would not have prescribed cephalexin.

Additionally, the doctor discussed potential risks of continuing cephalexin and cefuroxime with the patient and their son due to the allergy. The patient consented to the proposed treatment plan, and the doctor advised them to diligently monitor for any symptoms or allergic reactions.

It was also emphasized that the patient had been treated with these medications for an extended period before the development of the skin rash and facial swelling, which occurred approximately a month later.

After examining the evidence, the MMC rejected the complaint.

Discussion

While it is impossible to ensure patients will not develop drug allergies, establishing a safety net to alert them to potential allergic reactions is crucial. Patients should be educated about drug allergies and informed that reactions can vary from mild (rashes) to severe (breathing difficulties). Encouraging open communication prompts patients to disclose any known allergies.

Doctors must maintain an up-to-date allergy history for each patient encompassing details about the medications to which a patient is allergic, the types of reactions encountered and their severity. This record should be precise and accessible to all healthcare providers involved in a patient’s care.

Utilizing electronic prescribing systems can cut down on prescription errors by providing real-time access to patient data, drug details, allergy alerts, and dosage calculations. Doctors should embrace this technology to prevent errors due to illegible handwriting. Meanwhile, doctors should adopt the multidimensional strategies mentioned earlier.

Finally, it’s essential to stay informed on updates to regulations and guidelines related to prescribing medications. The Pharmacy Board of Malaysia and the MMC periodically update their guidelines, so doctors should regularly research latest information or consult with their professional organizations for guidance. Additionally, doctors should consider seeking legal and ethical advice for specific prescribing practice questions or concerns.