Page 31 - Risk Reduction Series Effective Systems Part 2

SVMIC Risk Reduction Series: Effective Systems

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 was given at discharge.
However, there, the cardiologist did not review the discharge

summary. If he had done so, this would likely have prompted
immediate action to contact the patient. Additionally, the patient

was seen by different cardiologists after his discharge, and the
amiodarone dosage was not verified at any of these office visits.

And, finally, the abnormal lab results had no follow-up.

Special Considerations for Prescribing and

Dispensation

A policy for prescribing and dispensing all drugs should be
developed and closely monitored by physicians.

The policy should include:

• Procedures regarding control and security of prescription
pads: prescription pads should be kept in a locked location

not accessible to patients or visitors.

• Restrictions on DEA numbers: reasonable precautions

should be taken with DEA numbers to limit availability to

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