This month’s claim study involves the care of a 31-year-old woman with a history of bipolar disorder and schizophrenia who was brought to a local emergency room for suicidal ideations. A Physicians Emergency Certificate was issued. The patient was placed in an inpatient facility bed and discharged after a treatment period of three days. She was released on multiple medications including prescriptions for Norco and Xanax, and all discharge medications were filled the same day as her release. The physician also ordered that the patient was eligible to refill an additional 40 tablets of Norco after 30 days.
Approximately 16 days after discharge, the patient was brought to a different area hospital emergency department. A Coroner’s Emergency Certificate was issued after she presented with suicidal and homicidal ideations following an argument with family after running out of Xanax. These records note the recent discharge from an inpatient facility two weeks prior. After a three-day stay, she was discharged with additional prescriptions for clonazepam, divalproex, trazodone, Lasix and KCI.
At this point, the patient also obtained the refill for her prior prescription of Norco.
Two days later, the patient presented to her follow-up outpatient clinical visit with the initial inpatient facility. She did not disclose the interim admission to the second facility or the medications she was given during the visit. Of note, the interim facility also failed to document that they notified the treating physician of her interim admission. The nurse practitioner who evaluated the patient on this visit increased her dosage of Xanax. The patient was advised to return to the clinic in one month.
Unfortunately, the patient expired from a drug overdose four days after this clinic visit.
Despite various defense arguments made, the Medical Review Panel determined there was a breach in the standard of care by both the prescribing physician and the nurse practitioner. They specifically opined that the physician breached the standard of care by prescribing a combination of high dosage benzodiazepine along with an opiate medication in a patient with known substance dependence. While a breach was also found on the part of the nurse practitioner involved, the panelists stated that this breach did not contribute to the patient’s death as the new prescription was not filled prior to the patient’s death.
This scenario is a very difficult one for healthcare providers. Patients seeking care in multiple clinics and emergency departments pose a difficult challenge to the healthcare provider trying to manage care. Patients with these types of psychiatric issues are often poor historians and do not always show responsibility for their own care. All of these concerns can result in an inaccurate health history that could compromise their own care (in this case, the patient’s life) and prevent optimal healthcare decisions.
Thirty percent of overdoses involving opioids also involve a benzodiazepine such as Xanax (alprazolam) and Klonopin (clonazepam), according to the National Institute on Drug Abuse in 2018. In addition, patients taking both an opioid and a benzodiazepine are at a higher risk of ED visits and drug-related inpatient admissions and have a death rate 10 times higher than patients who take opioids only as monotherapy. A red flag should be raised anytime a physician writes a prescription for an opioid and a benzodiazepine as co-therapy for a patient. Overall, this case seems to resonate with a lack of communication and a poor process for reconciliation of medications. It seems as though the only prescriber who was aware of the Norco prescription being given along with the benzodiazepines may have been the original prescribing physician.
- Communicate with the primary care provider regarding the patient’s plan of care. It appears that the patient records from the Emergency Department visit indicate a prior hospitalization that should have included medications prescribed at discharge. However, it is unclear as to why the healthcare professionals during the second inpatient stay did not communicate with the first regarding the patient’s plan of care. This communication could have provided a better picture of the patient’s health issues as well as a more accurate record of her current medication therapy.
- Conduct a thorough medication reconciliation process upon each visit. The process of medication reconciliation is a best practice in regards to obtaining the best possible medication history for a patient. Although the process is not always quick or simple, every effort should be made to contact the patient’s local pharmacies and primary care providers in order to ensure a thorough reconciliation of medications. This process could have potentially assisted the second inpatient facility in identifying a prescription for Norco that had been filled.
- Queries to the Prescription Monitoring Program (PMP) should become a habit to licensed independent practitioners (LIP). Louisiana requires that LIP query the PMP prior to prescribing opioids. However, it would also be prudent for LIPs to get into the habit of querying the PMP for patients who require benzodiazepine prescriptions or for those with high-risk behaviors in order to ensure safe prescribing practices. In this case, it is not clear if the second inpatient facility was aware of the patient’s Norco prescription. Although no opioid prescriptions were given to the patient upon discharge from the second facility, a benzodiazepine was prescribed. In conjunction with the patient’s history, this would warrant query to ensure no issues would conflict with safe prescription of this drug.
- Evaluate physician prescribing and refill practices. According to Louisiana laws, Norco is a Schedule II drug which prohibits refills. Therefore, a patient should be reassessed prior to reordering these medications and another prescription should be given based upon the results of the assessment. In addition, Louisiana laws also limit the quantity of short-acting opioids per 30-days which the prescription of 40 certainly exceeds.
- Patient education should be documented. All drugs can be dangerous and the ones in question with this case are particularly dangerous when given together. Patients should be educated on the medications that they are prescribed, including dangers, side effects and the importance of taking them according to the prescription. Medication education should be documented in the record as well as the patient’s response. It is important to demonstrate proper education was provided to the patient on the serious consequences of taking medications improperly.
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