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Claim Study: Medication Decisions for Chronic Pain Patients

 

FROM THE CLAIMS CONSULTANT

by: Jamie Lamb, Senior Claims Consultant

Chronic pain patients can be problematic when trying to help them manage their pain with a course of care that will provide maximum benefit with the least amount of risk. Prescription medications, specifically steroid medications, come with significant risk when used for anything other than short term treatment.

Our case study this month involves the care of a 53-year-old male with an extensive medical and surgical history including multiple orthopedic surgeries, kidney stones, carcinoma, degenerative disc disease and chronic prostatitis. When other non-steroidal medications failed to alleviate the patient’s symptoms, short rounds of Prednisone were initially prescribed. While there were gaps in time when the patient was not on Prednisone, the short rounds evolved into long-term prescriptions of 10mg of Prednisone as it was the only medication that provided him relief. The patient was almost consistently using the medication over a period of ten years. An appropriate referral was made to a rheumatologist; however, because of absent laboratory makers for inflammatory arthritis, no specialist care was given.

After ten years of Prednisone use, the patient was diagnosed with osteoarthritis secondary to chronic steroid use. While the physician said he explained all the risks and education provided to the patient about long term use of Prednisone, it was not charted clearly about how much the patient was educated regarding side effects. There was also a lack of documentation that the physician had laid out any plan for monitoring these potential side effects with the patient.

Defenses were raised on behalf of the physician including that facts that the patient was a life-long smoker with a history of alcohol abuse. The patient also tested positive for THC from a urine screen during the course of his care. It was argued that these factors were known to cause osteopenia and not the 10mg dosage of Prednisone. The Medical Review Panel found that the treating physician deviated from the standard of care. This decision was specifically based on the lack of documentation that the potential risks were clearly and regularly discussed. While the panel agreed the patient’s lifestyle played a significant role in the condition, the breach of lack of charting of thorough and continuous patient education was also a contributing factor.

FROM THE PATIENT SAFETY CONSULTANT

by Allison Rachal, RN-BC, Senior Patient Safety Consultant

Physicians should educate patients on all medications they prescribe pertaining to the type of medication, reason for medication, medication dosage, side effects associated with the medication, duration of therapy, and consider the cost of all pharmaceuticals. It is crucial that all of this information is documented and includes the risks that are increased due to the patient’s age, medical history, long-term treatment and compatibility with other medications the patient is currently taking. Physicians should review patient medication on every visit or with any changes in the patient’s medication regimen.

Documentation is essential in explaining these risks on a regular basis particularly in long-term medications that pose a higher risk to the patient’s health. In this case, steroids were prescribed that as long term therapy to a patient with multiple comorbidities which placed the patient at a higher risk of experiencing side effects. He also was immunocompromised with a history of carcinoma in which corticosteroids are commonly prescribed as adjuvant analgesics for pain in cancer patients. One of the side effects of corticosteroids includes osteoporosis.

This patient was at a high risk of developing osteoporosis due to his history of multiple orthopedic surgeries and degenerative disc disease. Steroid risks increase with long term use as evidenced in this case. There was lack of documentation that the physician discussed any of these above factors related to steroid therapy or the patient’s increased risk associated with taking this medication. This goes back to the saying, “If you didn’t document, you didn’t do it.”

The following are appropriate methods to prescribing medication and communicating critical elements to patients:

  • Explain the classification of the medication being prescribed
  • Explain the purpose of the medication being prescribed
  • Explain the direction of medication being prescribed
  • Explain the adverse effects associated with the medication being prescribed
  • Explain the duration of medication being prescribed
  • Evaluate medication therapy regularly
  • Consider the cost of medication being prescribed
  • Documenting education in the patient record

For more related risk reduction consultation or should you have questions about this subject matter, please contact your Claims and Risk Service Team members:

Mike Walsh, AIC, CPCU
Liability Claims Manager
225.368.3815
Stacie Jenkins, RN, MSN
Sr. Director of Quality & Patent Safety

318.227.7206
Allison Rachal, RN-BC
Sr. Patient Safety Consultant
318.227.7207
Michelle Schouest, RN, BSN
Sr. Patient Safety Consultant
225.368.3836