practice partner
Patient Safety
We use this forum to regularly report on findings from patient safety organizations, expert review
committees of the Office of the Chief Coroner, and inquests.
Medication error
went undetected
by health-care
professionals
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A
but preferred to have her disease controlled by predniCommittee of the Chief Coroner’s Office
sone rather than adding a disease modifying agent.
reviewed a death involving a medication
By November 2010, she was requiring significant
error after concerns were identified about
amounts of narcotic to control her pain, and the atpossible systemic issues in the detection and
tending physician contacted the rheumatologist who
communication of such errors.
had seen her before her admission to the long-term care
“Patient safety in any venue requires a team aphospital to determine if methotrexate
proach,” stated a report of the Geriatric
or other medications could be started.
and Long-Term Care Review ComThe rheumatologist indicated that
mittee. “Although the doctor wrote
“Although the doctor
there was no absolute contraindication
an incorrect order, there were opportunities for the pharmacist and nurses
wrote an incorrect order, to restarting methotrexate and recommended initiating a dose of 10 mg/
to recognize this error. Nurses and
there were opportunities week. The rheumatologist also asked
pharmacists have an important role
for the pharmacist and the attending physician to review the
to play in medication safety, and they
monitoring required to use methotrexshould be encouraged to exercise that
nurses to recognize
ate and the side effects, which were
role,” the report stated.
this error.”
available on his website.
The patient was a 56-year-old female
The attending physician downloaded
who had been a resident in a long-term
the information on methotrexate and
care home for more than a year before
faxed it to the long-term care home, along with the
her death. She was physically disabled from severe rheuprescription for methotrexate.
matoid arthritis, but cognitively well enough to direct
The attending physician wrote an order for methoher own care.
trexate 10 mg daily rather than the agreed upon dose
In September 2009, the patient was admitted to a
of 10 mg weekly. Folic acid 5 mg daily and monthly
long-term care home and continued to have symptoms,
Issue 1, 2016 Dialogue
27