Thematic Analysis of Obstetric Anesthesia Cases From the AANA Foundation Closed Claims Database

Maternal morbidity and mortality in the United States continues to be high. Understanding parturient complications and causes of death is critical to determine corrective actions. Analysis of closed malpractice claims evaluates patient care, identifies preventable morbidity and mortality, and offers recommendations for improvement. A review of obstetric anesthesia malpractice claims filed against nurse anesthetists (N = 21), extracted from the American Association of Nurse Anesthetists Foundation Closed Claims database, was completed. The malpractice claims included 18 maternal claims and 3 neonatal claims. The most common adverse maternal outcomes were maternal death (8/18) and nerve injury (4/18). Hemorrhage accounted for the greatest number of maternal deaths (3/8) followed by cardiovascular failure, emboli, and neuraxial opioid overdose. All neonatal claims (3/3) involved hypoxic encephalopathy resulting in 1 neonatal death and 2 cases of neonatal permanent brain injury. The majority of maternal cases were identified as nonemergent (15/18) and involved relatively healthy patients (15 identified as ASA physical status 2). Qualitative analysis of closed claims provides the opportunity to identify patterns of injuries, precipitating events, and interventions to improve care. Themes related to poor outcomes in this study include care delays, failed communication, incomplete documentation, maternal hemorrhage, and lack of provider vigilance.

National Rules for Drug-Drug Interactions: Are They Appropriate for Tertiary Hospitals?

The application of appropriate rules for drug-drug interactions (DDIs) could substantially reduce the number of adverse drug events. However, current implementations of such rules in tertiary hospitals are problematic as physicians are receiving too many alerts, causing high override rates and alert fatigue. We investigated the potential impact of Korean national DDI rules in a drug utilization review program in terms of their severity coverage and the clinical efficiency of how physicians respond to them. Using lists of high-priority DDIs developed with the support of the U.S. government, we evaluated 706 contraindicated DDI pairs released in May 2015. We evaluated clinical log data from one tertiary hospital and prescription data from two other tertiary hospitals. The measured parameters were national DDI rule coverage for high-priority DDIs, alert override rate, and number of prescription pairs. The coverage rates of national DDI rules were 80% and 3.0% at the class and drug levels, respectively. The analysis of the system log data showed an overall override rate of 79.6%. Only 0.3% of all of the alerts (n = 66) were high-priority DDI rules. These showed a lower override rate of 51.5%, which was much lower than for the overall DDI rules. We also found 342 and 80 unmatched high-priority DDI pairs which were absent in national rules in inpatient orders from the other two hospitals. The national DDI rules are not complete in terms of their coverage of severe DDIs. They also lack clinical efficiency in tertiary settings, suggesting improved systematic approaches are needed.

[Preventing interruptions during the administration of medicines]

The medication use pathway is a complex process with a high risk of error, all the more so if it is interspersed with interruptions. Interruptions during care procedures are a real problem which can result in serious adverse events. A legal frame obliges the health institutions to secure the administration of medicines. This priority objective is translated by risks assessments, tools of self-assessment, audits, corrective actions, which allow a raising awareness of the professionals to the risks associated to medicines.

Pharmacy legislation: public protector or professional hindrance?

Pharmacy originates from a background of medication compounding and supply. More recently, this role has developed away from an absolute focus on the supply of pharmaceuticals with, for example, the advent of pharmacist prescribing. Nevertheless, for a majority of the profession, medication supply remains a core activity. Regulation of the pharmacy profession is now the responsibility of the General Pharmaceutical Council, although up until 27 September 2010, this role fell to the Royal Pharmaceutical Society of Great Britain (RPSGB). Before this change, in one of the most high-profile legal cases involving a pharmacist in a professional capacity, R. v Lee, a pharmacist was prosecuted firstly for gross negligence manslaughter, later revised to offences under the Medicines Act 1968, for a single error relating to medication supply, and was given a suspended custodial sentence. Offences against sections 64 or 85 of the Medicines Act are absolute offences and there is no due diligence defence. Prosecution of a pharmacist for the supply of incorrect medication may seem a measured course of action to protect the public from the wrongful supply of potent pharmacotherapeutic agents; however, further analysis of Lee indicates that this approach may be counterproductive. An appeal of the original conviction in the Lee case has resulted in a clarification of the interpretation of section 85(5); however currently, prosecutions under section 64 are still a possibility. Owing to the seriousness of a criminal conviction under section 64, this continuation will potentially stifle the profession's ability to learn from dispensing errors.

Pharmacists' liability: what my pharmacy law professor did not cover

This article summarizes a practicing pharmacist's take on the liability of pharmacists in current pharmacy practice. The author, who feels that compounding pharmacists should be held to the same standards as other healthcare providers in civil litigations, provides a look at what he considers "entrapment" by way of legal double standards between independent pharmacy and big pharma.

[Psychiatric polypharmacy: hazard through drug-drug-interaction and possibilities for prevention]

Psychiatric diseases and comorbidity have increased over the past years. Commonly used psychotropic drugs contain a high risk of drug interactions and adverse drug events (ADE). With a frequency of 10-12% psychotropic drugs are, among all pharmaceuticals, the most common cause of hospitalisation due to ADE. During a hospital stay the application of psychotropic drugs can also lead to adverse drug events--sometimes due to drug interactions. Currently, ADEs and drug interactions are the most frequent cause of death for in-patients (18% of all causes of death) with an overall mortality of 0.95%. As studies have shown, hospitals as well as insurers could save a considerable amount of resources by implementing a system with on-ward pharmacists, hereby reducing ADE and re-hospitalisation rates. In recent studies a large amount of current ADEs were rated as preventable. Patient impairment due to ADE is leading to an increase in liability cases with an expected 5% increase of compensation payments in 2011. To evaluate these ADE-related cases, a pharmaceutical assessment should be included in the expert trials, especially since a lack of awareness of medication errors is prevalent. When aiming towards a successful drug therapy, physicians must also consider that cheaper substances may often have an unfavourable drug interaction profile.

Responsiveness to the chlorhexidine epidural tragedy: a mental block?

Paralysis following an epidural anaesthetic is a rare event. The mechanism usually involves accidental injection of skin antiseptic instead of local anaesthetic. Two recent cases, one involving paralysis, the other a "near-miss", are described. The first case resulted in an extensive root cause analysis and an admission of liability by the hospital. The response of the anaesthetic community and the New South Wales Department of Health was swift but failed to produce uniform protocols across the region. Furthermore, the requirement of medical staff to double check medications with a second person before their administration was not addressed. Abandoning a more effective but neurotoxic antiseptic solution in favour of a solution with weaker antiseptic properties, as had previously occurred in one Sydney hospital, could incur higher risks of epidural infection. Defensive medical practice can lead to unwanted negative consequences.

Diagnostic failure of ciprofloxacin-induced spontaneous bilateral Achilles tendon rupture: case-report and medical-legal considerations

Rare side-effects of fluoroquinolone therapy are tendinitis and tendon rupture. Many reports have demonstrated that the concomitant use of corticosteroids, in patients aged 60 years or older, increase the risk substantially. We present a case of spontaneous bilateral Achilles tendon rupture induced by ciprofloxacin and methylprednisolone. A 61-year-old woman was diagnosed with Bronchiolitis Obliterans with Organizing Pneumonia (BOOP) and was started on oral ciprofloxacin 500 mg twice daily for 3 weeks and on oral methylprednisolone 16 mg twice daily for 2 weeks. The diagnosis was made after doctors, rather than stop drug therapy and advise complete rest, had mistakenly prescribed for the woman to undergo physiotherapy and local NSAIDs, thus favoring the onset of tendon ruptures and resulting in surgical and legal implications. Inspired by this case, we also submit a brief review on professional liability in Orthopaedics.

[Fatal sodium chloride intoxication--case report and review of the literature]

The authors describe the case of a 63-year-old, female nursing home inhabitant suffering from trisomy 21, who accidentally ingested the anti-epileptic medication of another nursing home inhabitant. After telephone instructions from a specialist in internal medicine, caregivers forced the woman to vomit by means of saline solution and digital manipulation. This caused not only substantial hypernatriaemia but also aspiration pneumonia, from which the woman died after short hospitalization. The potential toxicity by major electrolyte shifts in terms of hypernatriaemia following administration of sodium chloride solution is well known; this measure is medically contraindicated for the induction of vomiting. The mechanisms leading to death in this case are presented, differentiated and discussed against the background of the literature.

Adverse effects

In medicine, an adverse effect (AE) is a harmful and undesired effect resulting from a medication or intervention and procedures. Some AEs only occur when starting, increasing or discontinuing a treatment; in this case they are a function of dosage or drug levels at the target organs, or they may also be caused by drug interactions. The distinction between adverse and non-adverse effects is a major undertaking when a new drug is developed and tested. Studies are used to define the dosage to be used in human testing (Phase 1) as well as to calculate the maximum admissible daily intake. Imperfections in clinical trials sometimes lead to public health disasters and the withdrawal of the drug from commerce. Surgery may have a number of undesirable or harmful after-effects. Diagnostic procedures may also have AEs, depending much on whether they are invasive, non-invasive or minimally invasive. In clinical trials, a distinction is made between AEs and Serious Adverse Events (SAEs). Generally, any event which causes death, permanent damage, birth defects, or requires hospitalization is considered an SAE.

Pharmacists' responsibility and potential liability regarding generic substitition

The generic medicines market in Australia is continuously growing and there is a push by the government towards generic substitution. However, generic dispensing places additional time constraints on pharmacists. There is also an increased need for professional judgement, and hence increased risk of error. Generic dispensing consequently places an increased responsibility on pharmacists, with a subsequent increased practice and liability risk. It is therefore important that pharmacists implement good practice standards and guidelines in order to manage their liability with regard to generic dispensing in both community and hospital pharmacy practice.

Nursing liability and chain of command

SCENARIO: A FIVE-DAY-OLD INFANT is diagnosed with systemic Candida albicans (yeast). During rounds, the resident physician is told to start 5FC (flucytosine). When the order is written, it is for 5FU (fluorouracil, a cancer drug). The medication arrives on the unit; the nurse checks it against the order and determines that it is for the right patient, right dose, right route, right time, and, according to the order, right drug. The infant receives the drug from nurses on two shifts. The nurse on the night shift, a new nurse, asks why the infant is receiving a cancer drug. She calls the pharmacy to question it, then calls the resident physician and is told that it was what the attending physician said to order. Despite the nurse’s insistence that this is not the right drug, the resident demands that she give the drug as ordered. She gives the drug. The next morning the infant dies. A lawsuit is brought in which the resident, attending physicians, and hospital are named as defendants. The hospital is sued because of the negligence of its nurses who failed to question the order to give 5FU.