A Primer for Attorneys

by Allison Muller

The Not-So-Obvious Medication Misadventure

Medication adverse effects are not always obvious, even to the trained medical professional. There are reasons for this. A patient may have medical conditions that cloud the picture of an adverse drug reaction. There may have been a medication error (that is, wrong drug, wrong dose, or wrong patient) but it went unnoticed. The medication error was noticed but not reported by the health care provider for fear of retribution despite a “just cause” culture.

There are some scenarios that may send some red flags up that there was harm done to a patient by medication. The simplest (but unfortunately least likely) scenario is when a healthy patient, taking no other medications, says “I just started taking this medication, and as soon as I started taking it, something went wrong”. And the “what went wrong” part has been well-documented in the medical literature. But harm from medications is not always that easy to detect.

As a toxicologist, the first thing I am looking for when reviewing medical records is, was there a chance that any of the drugs given to a patient could have contributed to the patient’s medical condition. And of course, if a medication harmed a patient, how can this harm be prevented in other patients.

For attorneys, there are the “Top 5” things to think about when reviewing details of a medical case, which may or may not be a medication error case from the get-go. Of course a toxicology or other medical expert may be at your fingertips, but here are some tips for attorneys before that step is even a thought:

1 Did a patient receive too much medication?

The dose makes the poison. As a toxicologist, this is one of my favorite sayings. There is so much truth to it. Yes, a drug or even a chemical can have a lot of dangerous effects associated with it. But the question becomes, how much was the patient actually exposed to? That is not always easy to answer. In the case of a hospitalized patient, we can only go by what is documented in the chart, and we hope that the documentation is accurate. In the case of a patient who returns home with prescriptions, we don’t know with certainty if the patient was taking the drug as prescribed. Or, we don’t know if the patient was taking a drug even intended for them.

2 Was a medication appropriate for a patient?

The dose makes the poison. But…even a “normal” dose may be harmful to a patient. How can this be? Didn’t we just ascertain that the dose makes the poison? That is not completely true. Some other scenarios can be at play here. For example, were there other medical conditions that made a certain drug less tolerable and more toxic to a patient? Were there medications that interacted with one another intensifying the effect of one or more of the drugs or extending the time the drug stayed in the body? As an attorney, don’t write off a possible medication adverse reaction just because the dose was acceptable.

3 The dose of the drug was fine. Or…was it?

What is an acceptable dose of a drug? Sometimes the answer is very patient-specific. There are drugs with very narrow margins of safety. That is, a little bit off from an acceptable dose can lead to harm. Some drugs are based on the patient’s weight. Is there a weight documented in the medical records? Or was an “average adult” weight used to calculate the dose? This one is a little trickier and probably warrants a call to a medical expert.

4 Were any antidotes included on a patient’s drug list? If so, why was it used?

An antidote is used to reverse the effects of a drug. An attorney may not know why an antidote was used when it is encountered in a medical record. For example, was it simply to reverse the effects of anesthesia? Or was a drug given in an excessive amount and now its effect needs to be reversed by an antidote? Or did a patient have an adverse reaction to a drug that needs to be treated? It’s helpful to know why each and every drug on a medical record was used. You may be surprised what you find out.

5 I see drug levels. Why are they here and what do they mean?

Keep an eye out for drug levels in medical records. Why were they performed? Was it for routine monitoring of a patient or was it because there was an adverse medication event?  Interpreting drug levels are challenging. Drug levels do not always correlate with how sick a patient is or will become. Drug levels are measured in different ways, and the interpretations of these tests is a science in itself. Keep your radar up when you see drug levels in a medical chart. But discuss them with a medical expert to help you connect the dots. Connecting the dots is what medical experts are there for.

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