The Doctor’s Advocate | Second Quarter 2017
An Ounce of Prevention
The Doctors Company Introduces a New CME Series
We are constantly looking ahead to offer you more informed patient safety and risk management resources, clinical trends, and patient outcome information. We are pleased to introduce a complimentary new on-demand series that lets you earn CME credit for reading designated articles online and completing a post-test and evaluation.
The first course in our article series, Perspectives on Opioids and Pain Management, is based on the analysis of data from several studies discussed in The Doctor’s Advocate (articles by Dr. Roneet Lev and Dr. David Troxel in the first quarter 2017 issue and the lead article by Dr. Howard Marcus on page 3 of this issue). The course is approved for 1 AMA PRA Category 1 Credit™.*
To get started, here is a preview of the information covered in Perspectives on Opioids and Pain Management with a sample of the post-test questions. Find the full articles, post-test, and evaluation at thedoctors.com/perspectivesCME.
Physicians in virtually all specialties assess and treat patients who are in discomfort. Pain medication and pain control are the focus of many educational programs aimed at addressing the ongoing epidemic of opioid misuse. We believe The Doctors Company can contribute insights to help doctors better recognize potential issues and manage the medications used to treat pain. By sharing information that we have gleaned from analyzing professional liability claims and other data, we hope to enhance safety and reduce potential medical malpractice liability exposures that may arise from pain management practices.
- An 84-year-old female, status post-fall with rib pain, was briefly hospitalized (23-hour observation) and given two doses of Dilaudid (0.5 mg each). A fentanyl (25 mcg/hour) patch was placed just prior to discharging the patient home. At 2:10 AM the following morning, the patient was found unresponsive in bed and could not be resuscitated. Select the action that would have made the most difference in the outcome for this patient:
- a. Monitoring the patient for 24 hours when starting fentanyl for the first time.
- b. Educating the family regarding the risks of medications.
- c. Selecting a different long-acting opioid preparation.
- d. Conducting a medication reconciliation prior to discharge.
- A 16-year-old male with a body mass index of 35 and a known history of obstructive sleep apnea underwent a shoulder arthroscopy. The physician ordered postoperative morphine by patient-controlled analgesia (PCA) pump. An hour later, the order was for a “double dose” via PCA pump. The patient was transferred from the postoperative recovery area to a general nursing unit. Twelve hours later, the patient was found unresponsive and could not be resuscitated. No more than 50 mg morphine (total dose) had been delivered by PCA pump during that time period. The autopsy drug testing confirmed the presence of Valium and marijuana (not prescribed by the physician). Select the action that would have made the most difference in the outcome for this patient:
- a. Educating the patient/family about the risks of medications.
- b. Using pulse oximetry to monitor the patient.
- c. Conducting a medication reconciliation on transfer to the floor.
- d. Depending on family member(s) to monitor the patient.
- In The Doctors Company analysis of closed claims that resulted in patient harm, all of the following were identified as contributing factors, except:
- a. Inappropriate selection and management of therapy.
- b. Patient factors, including noncompliance with treatment plans and follow-up appointments.
- c. Errors in patient monitoring.
- d. Communication errors with patients and their families, including insufficient warning of risks of opioids.
- e. Failure to conduct urine drug screening.
- f. Inadequate patient assessment for risks and contraindications to opioids.
- g. Failure in communication among providers.
- h. Insufficient documentation and/or support for clinical decision making.
- i. Failure to take psychiatric and/or abuse history.
- When prescribing narcotic analgesics in the outpatient setting, the prescriber’s greatest risk for a claim is:
- a. Underdosing.
- b. Death.
- c. Side effects.
- e. Informed consent.
- The Doctors Company closed claims study identified contributing factors for patients treated in outpatient settings. Select all that apply:
- a. Failure to follow physician instructions.
- b. Communication problems.
- c. Noncompliance with the treatment plan.
- d. Patient monitoring factors.
- e. Failure to keep appointments or make follow-up appointments.
- The Prescription Drug Monitoring Program can provide you with the following information. Select all that apply:
- a. Medication names.
- b. Patient diagnoses.
- c. Medication dosages.
- d. Prescriber names.
- e. Filling pharmacies.
- The number of deaths from opioid overdoses is lower than the death rate from motor vehicle accidents.
- a. True.
- b. False.
- Prescription opioids (mu receptor agonists) are less addictive than heroin.
- a. True.
- b. False.
- After rotator cuff surgery, a 66-year-old female was prescribed opioids to manage pain. The prescription for oxycodone-acetaminophen 5-325 mg was refilled twice, 30 pills each time. This was followed by a prescription for 40 pills of the lower-dose opioid, hydrocodone-acetaminophen 7.5-325 mg, with no refills. The prescribing physician did not ask the patient about the use of the opioids or about any other medications she was taking. The patient was told to take one or two pills every six hours. No education was provided about avoiding the risks or side effects associated with opioids. Based on the article by Dr. Howard Marcus, which action, if taken, is likely to be the most effective in preventing harm to this patient?
- a. Make the patient more aware of the risks of side effects in these dosages.
- b. Evaluate the risk factors more thoroughly when determining the opioid dosing.
- c. Evaluate the benefit and harm within one to four weeks of starting opioid therapy.
- d. Conduct a medication reconciliation.
Find details on this complimentary course and explore our extensive Education and CME options at thedoctors.com/cme. Look for more courses in our article series in upcoming issues of The Doctor’s Advocate.
*The Doctors Company is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
The Doctors Company designates this enduring material for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
The Doctor’s Advocate is published by The Doctors Company to advise and inform its members about loss prevention and insurance issues.
The guidelines suggested in this newsletter are not rules, do not constitute legal advice, and do not ensure a successful outcome. They attempt to define principles of practice for providing appropriate care. The principles are not inclusive of all proper methods of care nor exclusive of other methods reasonably directed at obtaining the same results.
The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.
The Doctor’s Advocate is published quarterly by Corporate Communications, The Doctors Company. Letters and articles, to be edited and published at the editor’s discretion, are welcome. The views expressed are those of the letter writer and do not necessarily reflect the opinion or official policy of The Doctors Company. Please sign your letters, and address them to the editor.