Page 5 - Hospitalists - Risks When You're the Doctor in the House (Part Two)

SVMIC Hospitalists - Risks When You’re the Doctor in the House

PART TWO

Medication Safety

A primary example of dropping the baton in a handoff is the

lack of medication reconciliation. Medication errors account for
a significant percentage of medical liability claims, and our data

at SVMIC reveals that medication-related issues are a leading
factor in malpractice claims. Closely monitoring medications

requires the utilization of standardized tools and guidelines
because patients are usually under the care of multiple medical

providers.

Clear communication and coordination between providers is
necessary for reliable medication reconciliation. For example,
recall the previous case study involving patient Mr. Richardson,

who received the excessive dosage of amiodarone. How could

this happen to a patient when there is a recognized protocol
for drugs such as 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. He also failed to acknowledge
his unfamiliarity with the medication or to contact an authority,
such as the hospital pharmacist, to obtain guidance on the

appropriate dosing strategy prior to the discharge prescription.

Following the patient’s hospital release, the cardiologist received
a copy of the hospital discharge summary which identified
the dose of amiodarone the patient was given at discharge.

Unfortunately, the cardiologist did not review the discharge

summary. Had he done so, he most likely would have taken
immediate action to contact the patient. Adding to the medical

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