In October of 2013, a 66-year-old retiree was treated for congestive heart failure. After her treatment, she was discharged with eight prescriptions for continued care, one of which was a diuretic called metolazone. However, instead of metolazone, the pharmacy technician wrote methotrexate on the prescription, a harsh medication usually prescribed to cancer patients. Methotrexate can damage organs, the lining of the mouth, intestines, stomach and can drastically reduce red blood cell counts. In fact, the recommended dose for methotrexate is never more than once or twice a week at a much lower dose than the patient was given. This patient was mistakenly given this deadly prescription drug and told to take it once a day.
Less than two weeks after being discharged from the hospital, the patient developed sores in her mouth and throat. Blood began leaking from her bowels and her nose. Eighteen days later, she was checked into the hospital. Three days later, she died of multiple organ failure. The patient’s doctors reported there was almost no blood cell count. It was a tragic and painful death.
Poor coordination and failure to communicate between health agencies can make the transition from hospital to home deadly for patients. This type of situation can occur with pharmacies, nursing homes, home health care and any other professional medical service designed to help patients recover at home.
Medication mistakes are the most common types of dangerous incidents that occur when a patient transitions from hospital to home, according to an article by The New York Times. The article goes on to say it is also common amongst older patients, whose medical needs can be more complex. A study found that from 2010 to 2015, inspectors reported more than 3,000 home health agencies, which is almost one-fourth of those examined by Medicare, had not properly traced or reviewed medications for newer patients. In some of the more extreme cases, nurses failed to identify when patients were taking dangerous combinations of drugs, which could cause bleeding, seizures, kidney damage, abnormal heart rhythms or death.
In this particular medical malpractice case, the patient’s pharmacist wrote the name of the prescription down incorrectly and made multiple spelling and dosage calculation errors. Additionally, the two nurses that visited the patient’s home every day failed to catch the medication error. The patient’s family was awarded $2 million in damages from the pharmacy last month. However, the state’s cap on medical malpractice damages lowered the award to $125,000. The family also received $225,000 from the medical center that discharged the patient.
There are so many factors at play when we attend even one doctor’s appointment. Between our insurance company, possible EMS responders, the hospital administration that handles our medical records, the doctors themselves, the pharmacy and any other at-home medical services we require, all of these entities need to correctly communicate between themselves to ensure we receive the proper care. Any one mistake, like a spelling error on a prescription, can make for a deadly situation.