How pharmacy miscommunication can result in patient death: Case study

A jury awarded $42.4 million to the estate of a patient who died after staff failed to get the patient's baclofen prescription filled in a timely manner, a case study posted on the American Pharmacy Association website said.

The patient was taken to an unnamed Illinois emergency department on a Friday because his intrathecal baclofen pump, which delivers the muscle relaxant medication directly to the spine, required surgical replacement. The patient was experiencing baclofen withdrawal and their physician "told the emergency physician about the concentration of baclofen that [the patient] required, which was 2000mcg." The patient was scheduled for pump replacement surgery on Monday morning, but the order for the prescription was delayed by hours. When the order was finally received, the pharmacy learned that it didn't have the correct concentration, resulting in another hourslong delay. 

The patient coded at 3:10 p.m. on Monday, nearly two hours before the correct medication was obtained. The patient was stabilized but did not regain consciousness. The successful surgery was performed around 5:30 p.m., but the patient was placed on life support and died two weeks later.

The patient's estate sued the hospital, alleging it "allowed a system failure to exist, resulting in the delay of [the patient] receiving his intrathecal baclofen, and/or failed to ensure effective communication among [the patient's] healthcare providers." A jury found the hospital guilty of institutional negligence.

The hospital appealed, but the ruling was upheld. The appellate court judge wrote that the hospital was responsible for procuring the correct equipment and medication for the surgery and affirmed the jury verdict of institutional negligence.

The case study noted that such issues can be avoided with effective communications protocols. "Effective communication systems can facilitate interdepartmental messaging," the author wrote. "For example, a systematic communication avenue is necessary when the emergency department learns on Friday that the pharmacy department will need to supply an infrequently used medication to the surgery department on Monday.

"Notations in electronic records indicating the need for specific medications should be immediately routed to the pharmacy department so that a sufficient supply of medication can be obtained to meet patient care needs."

Copyright © 2024 Becker's Healthcare. All Rights Reserved. Privacy Policy. Cookie Policy. Linking and Reprinting Policy.


Featured Whitepapers

Featured Webinars