Medscape Editor’s Key Points:
In order to avoid inadvertently overprescribing a medication, it's important for physicians to create specific routines, such as reviewing a patient's medication flow sheet when issuing refills.
These routines are typically more effective than assuming that the patient remembered the doctor's verbal advice, or that patients followed the warning on the label.
The Case
Yes, prescription medications often contain detailed information sheets or warning labels. No, these warnings will not relieve the prescribing physician of his or her responsibility to monitor the patient's actual use of the medication in the refill process.
A patient in her early 40s complained to her primary care physician, Dr PC, of a 10-year history of eye irritation. She told him that because nonprescription eye drops were no longer effective, she wanted a prescription. Dr PC assessed the patient as having allergic conjunctivitis and referred her to an ophthalmologist.
She complained about her eyes being red and painful again 5 months later, at which time Dr PC again referred her to an ophthalmologist. During the patient's visit 2 years later for a cough and sore throat, Dr PC documented the patient's chronic red eyes and noted that antibiotics had not helped her. Dr PC referred her to a different ophthalmologist.
In a visit a year later, the patient complained that the area around her right eye had been red for more than a month. Dr PC prescribed Tobradex® (tobramycin/dexamethasone), a steroidal anti-inflammatory and antibiotic, and advised her to follow up with an ophthalmologist if she did not improve. When the patient called the next month asking for a refill, Dr PC called back to ask if she had followed up with an ophthalmologist. She responded that she had seen several ophthalmologists, who diagnosed chronic eye irritation and allergies, and who gave her drops to use daily. But she told Dr PC that she also had flare-ups of "pink eye" and that the Tobradex worked the best for that.
Dr PC approved the refill but charted that he advised the patient that Tobradex was not for continuous use because it could cause glaucoma and cataracts. He again instructed the patient to follow up with her ophthalmologist.
Dr PC approved telephone requests for refills twice again several months later, and when the patient called early the next year for another refill, Dr PC approved it and advised her to follow up with her ophthalmologist. A few months later, the patient called, complaining that the Tobradex was not helping the continued redness around her eyes.
She was told to come in to the clinic for evaluation or to see her ophthalmologist.
Early the next year, the patient returned to Dr PC with a variety of complaints, including a request for a referral to another ophthalmologist for possible cataracts.
The ophthalmologist indeed diagnosed cataracts and later reported to Dr PC that the patient had been using the Tobradex four times a day for 2 years. When Dr PC spoke with the patient over the telephone about the diagnosis, he explained that the cataracts had probably been caused by the Tobradex. When he noted to the patient that the label on the medication advised against using the medication for more than 5 days, the patient responded that she was never told to follow directions or read the labels.
The patient sued Dr PC and her pharmacy for the damage to her eyes from the Tobradex. The dispute resolved without going to trial.
Physicians can avoid inadvertent overprescribing by developing specific routines—such as reviewing a patient's medication flow sheet—when issuing refills.
Such routines can be more effective than simply assuming that the patient remembered the doctor's verbal advice or followed the warning on the label, important as those latter two certainly are.
This case comes from Medicine on Trial, originally published by Cooperative of American Physicians, Inc., to provide risk management lessons from litigated case histories.
© 2018 Cooperative of American Physicians, Inc.
This case comes from Medicine on Trial, originally published by Cooperative of American Physicians, Inc., to provide risk management lessons from litigated case histories.
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