Tuesday, July 19, 2016
This Is A Pretty Sad Story With An Important Lesson Or Two Regarding Use Of Prescribing Systems.
This very sad story appeared a little while ago.
6 July, 2016|
A country GP who prescribed contraindicated antihypertensives to a pregnant woman whose baby died has put the error down to 'red flag' alerts being switched off on his software.
Dr Sunil Kumar Dan, a 73-year-old GP who has practiced in Moree in NSW for more than 30 years, has been found guilty of unprofessional conduct over the treatment of a patient during several antenatal visits in 2012 in a decision of the Medical Council of NSW’s Professional Standards Committee.
The woman was nine weeks pregnant during the first antenatal visit in July 2012 with Dr Dan, her GP of over 20 years who had been treating her for hypertension since 2009.
At the appointment, the woman presented with a BP reading of 115/79mmHg and left-sided chest wall pain, and Dr Dan noted she would stop taking Caduet due to pregnancy.
But when the woman returned one month later, the GP prescribed Micardis Plus despite recording her BP as 101/67 and the drug being contradindicated in pregnancy.
On 21 September, the woman returned at 17 weeks gestation, when Dr Dan recorded a BP of 100/50 and chest wall pain, and prescribed Caduet.
In November, Dr Dan prescribed the woman with a third contraindicated medication, Celebrex, for a knee complaint.
He later told the professional standards committee he had known at the time that this would mean she was now taking the so-called “triple whammy” combination of an ACE inhibitor, thiazide diuretic and NSAID which can result in renal failure, but he felt a short course of Celebrex was “preferable to doing nothing”.
The woman returned at 26-weeks gestation and again the GP prescribed Micardis Plus and Caduet.
The woman’s baby later died; however, it is not detailed in the decision whether this was in utero or following birth.
In its finding, the professional standards committee said the death was "likely to have been associated with the Micardis Plus and Caduet Patient A was inappropriately prescribed".
Lots more discussion here:
As you read the rest of the report it becomes clear that the GP was relying on the drug alert system in his practice system to make sure he was warned if he was prescribing medications which were not appropriate in pregnancy.
He claimed that the warning system had been turned off but surely that can’t be true. I can’t imagine any reason why, once a patient is recorded as being pregnant, anyone would not want to be warned if a drug was unsuitable for the pregnant and that any software provider would enable such a setting. For mine I would prefer to be warned if prescribing for women ‘of possible child bearing age’ if I was planning any medication that might threaten the child – so I could ask a few direct questions regarding pregnancy risk, and go from there.
This has to be one of a range of design decisions for practice / prescribing software that really must be carefully thought through to ensure patient safety, which is, after all the purpose of clinical software.
That said, we have to be clear it is the prescriber is ultimately responsible for all prescribing decisions and need to exercise more than due care at all times!
Posted by Dr David More MB PhD FACHI at Tuesday, July 19, 2016