E RRORS IN T RANSFER O RDERS Keith Lau, M.D. Department of Pediatrics McMaster University October 15, 2009

S ETTING A 75-year-old lady developed a methicillin-resistant Staphylococcus aureus (MRSA) in the hospital following knee replacement surgery Ccreatinine test that showed her kidneys were functioning normally After weighing the potential for harm from the infection and potential side effects from the medication

S ETTING Decided to include gentamicin, together with vancomycin and rifampicin, in her treatment regimen The course of gentamicin was to be very short Was to be discontinued prior to her transfer to a nursing home Discharge antibiotics would be IV vancomycin and oral rifampicin

D ISCHARGE ORDERS MIXED UP

S ETTING Attending physician was on vacation when the patient was transferred to the nursing home The nurse contacted the physician’s partner over the phone for the orders Then, the nurse drafted a Patient Transfer Form that accompanied the patient to the nursing home

S ETTING Contrary to the attending physician’s initial plan Gentamicin was included in the list of medications “gentamicin 120 mg IV piggybag every 12 hours, next dose, 9 pm today, 6/10”

S ETTING At the nursing home, the patient continued to receive IV gentamicin On day 3 after the transfer, the patient had trouble in urinating Creatinine was checked and was abnormally high

S ETTING Creatinine was repeated Gentamicin was not discontinue The result came back the next day, and was even higher and then Gentamicin was then stopped Patient suffered from acute renal failure that required acute hemodialysis

C ASE Plaintiff: Lady A Defendants: Hospital B Dr. C (ID specialist) Nursing Home D Dr. E (ID specialist) Nurse F (nurse of Hospital B) Dr. G (staff physician at Nursing Home D)

N URSE F ( EMPLOYEE OF H OSPITAL A WHO DRAFTED THE TRANSFER FORM ) Testified that: she drafted the transfer order (including the gentamicin) She spoke to Dr. E on the phone for the orders before lady A was transferred Dr. E was contacted because Dr. C was on vacation

N URSE F could not remember the particular conversation with Dr. E custom and practice would have been for Dr. E to ask her for the information contained in the chart she would have written the order exactly as Dr. E gave to her and would have read it back to him for verification

N URSE G ( PLAINTIFF ’ S NURSING EXPERT ) N URSE H (D IRECTOR OF NURSING OF N URSING H OME D) testified that: Expect a reasonably well-qualified nurse to know that gentamicin is nephrotoxic Nurse F deviated from the standard of care by listing gentamicin on the order because Dr. C did not call for it If Nurse F told Dr. E that Dr. C’s plan called for plaintiff to be placed on gentamicin, it was also a deviation from the standard

N URSE G ( PLAINTIFF ’ S NURSING EXPERT ) N URSE H (D IRECTOR OF NURSING OF N URSING H OME D) Transfer form provides a “continuity of care” Never seen a medication listed on transfer form that had been discontinued before the transfer

N URSE I ( NURSE AT N URSING H OME D) testified that: Relied on the medication list on the transfer form to prepare her own physician order form for the plaintiff Based on the transfer form, she believed that the plaintiff was to receive gentamicin

D R. E (G AVE THE TRANSFER ORDER OVER THE PHONE ) Testified that: He could not specifically recall the conversation with Nurse F It was his custom and practice to have the nurse convey to him over the phone the plan put in the chart by his partner Wanted to follow his partner’s plan

D R. E Would only have ordered gentamicin if he had been told the it was part of the plan Must have been mis-informed Agree that Nursing Home D was dependent on getting the accurate information from Hospital B as to what care the plaintiff should get after the transfer Based on how the transfer form was written, he would expect the staff at Nursing Home to continue the gentamicin

D R. J ( ATTENDING PHYSICIAN AT N URSING H OME D) Testified: Transfer form is “to give the doctor in the nursing home a guidance how to continue treating the patients” Up to him to determine whether to follow or not The orders appeared reasonable Decided to leave the medications as is

D R. J He was questioned on: Why he did not check blood tests for kidney functions for 2 days Why he did not discontinue the gentamicin after the creatinine came back to be abnormally high

D R. J Testified: Nursing Home did not check daily labs for kidney functions unless the patient had some known past history of kidney problems On a.m. of June 13, he was informed about plaintiff had trouble in urinating Did not stop the gentamicin at that time Concern about infection the MRSA infection might cause the plaintiff to lose a limb or her life

D R.K (P LAINTIFF ’ S KIDNEY SPECIALIST ) Testified that: As a result of the prolonged treatment of gentamicin The plaintiff suffered permanent kidney failure Would require dialysis for the rest of her life

P ROGRESS Plaintiff’s MRSA infection resolved favorably and she returned to live at home But now has permanent renal failure and required chronic hemodialysis 3 times weekly for the remainder of her life

C ONCLUSIONS No question about the negligence of the hospital nurse who did the paperwork for the transfer She misread the chart and failed to see that the gentamicin had been discontinued

V ERDICT The only defendant found liable: Hospital B based on Nurse F’s “negligently informing Dr. E that the long-term antibiotic plan from Dr. C was to include gentamicin” Dr. J was not liable Jury awarded plaintiff $3,200,000

T AKE HOME MESSAGE It is a challenge but important to ensure medicine reconciliation Patient transition points are especially vulnerable to medication errors Take extra time to review the list and if in doubt, ask Simple solution can go a long way to decrease medication errors