Page 66 - 2022 Risk Basics - Systems

SVMIC Risk Basics: Systems

the “same dose” of medication rather than specifically asking him

how much he was on. The office notes for these visits indicated he
was taking Amiodarone 200mg two times per day instead of the

actual dose of 400mg three times per day. The patient’s symptoms
worsened, and he experienced an increase in weakness, dizziness,

and gait instability, so carotid studies and liver function tests
were performed, but follow-up of the lab results was not done.

Two months later, which was now four months after the patient’s
discharge, the patient’s nephrologist identified the discrepancy in

the patient’s medication record and the abnormally high dose of
amiodarone that was on the patient’s medication bottle brought

into that visit.

The nephrologist phoned the cardiologist to verify that the patient
should be on this much medication. The cardiologist told the

nephrologist to have the patient immediately discontinue the
medication. A few weeks later, the patient was admitted with

ongoing symptoms of weakness, dizziness, and gait instability. He
suffered a stroke, pneumonitis, and polyneuropathy and expired

one month later due to the effects of the toxicity.

How did this happen to a patient when there is a recognized protocol

for drugs such amiodarone? First, the discharging physician prescribed
the medication without calling to discuss the discharge needs of the

patient with the treating cardiologist who ordered the amiodarone. In
addition to that, he also failed to acknowledge his unfamiliarity with the

medication and contact someone, such as the hospital pharmacist, who
could provide guidance on the appropriate dosing strategy prior to giving

the patient a prescription for discharge. Following the patient’s discharge,
the cardiologist received a copy of the hospital discharge summary. This

discharge summary identified the dose of amiodarone that the patient

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