Page 29 - Risk Reduction Series Effective Systems Part 2

SVMIC Risk Reduction Series: Effective Systems

CASE STUDY

continued
A 71-year-old male presented to the ER with chest pain

and atrial fibrillation. He had a cardiac workup, including a
stress test and trans-esophageal echocardiogram, and was

prescribed an anticoagulant as well as a loading dose of
amiodarone. The usual dosing strategy included a loading

dose of 400mg three times per day for one week and then
tapering to a maintenance dose of 400mg per day. Under

pressure from the family for the patient to go home, this
patient was discharged by an internal medicine physician

in the cardiologist’s multi-specialty group who wrote a
prescription for the amiodarone exactly as it appeared in

the patient’s medication record that day in the hospital,
which was 400mg three times per day. The discharging

physician later admitted in his deposition that he never
discussed the dose for the amiodarone prescription with

the cardiologist who had written the inpatient orders.
After the patient was discharged, a copy of the hospital

discharge summary, which included the medications and
dosages that were prescribed for the patient to take at

home, was sent to the cardiologist as well as the primary
care provider.

The patient returned to the cardiologist’s office one
month later, and the nurse incorrectly documented the

Amiodarone dosage as 200mg two times per day. At that
office visit, the patient complained of shortness of breath

and dizziness.

The patient returned to his cardiologist’s office two times

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