Your Practice Made Perfect

This podcast series provides support, protection, and advice for today’s medical professionals. Brought to you by SVMIC, a mutual insurance company that is 100% owned and governed by our policyholders.

Mar. 01, 2019

Episode 052: The Dangers of Miscommunication

Brian Fortenberry explores the closed claim case of a patient who, through miscommunication on various levels, died from a dosage error. Licensed CPA and attorney J. Baugh joins to discuss where the fault may lie and how to avoid issues like this in the future.

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Show Notes

"An Illusion of Communication" by J. Baugh

  • Transcript

    Speaker 1: You are listening to Your Practice Made Perfect, support, protection, and advice for practicing medical professionals, brought to you by SVMIC.


    Brian: Thanks for joining us today. My name is Brian Fortenberry, and today we're going to be looking at a closed claim case. Before we get into the discussion questions, let's look at the background and the story that we'll be discussing today.


    SVMIC has written articles and given seminars over the years about the importance of communication as it relates to providing medical care to patients. This particular article focuses on a case in which the breakdown in communication between physicians resulted in a medication loading dosage being continued inadvertently and is another reminder of how miscommunication between multiple physicians can result in harm to the patient.


    Randy Richardson, a 71-year-old male patient with multiple health issues was admitted to the hospital for treatment of chest pain. Mr. Richardson had a medical history of obesity, sleep apnea, high cholesterol, hypothyroidism, arthritis, and ulcers as well as a surgical history that included back surgery, thyroidectomy and transcatheter intravascular stent placement.


    Dr. Samuel Carter an interventional cardiologist diagnosed Mr. Richardson with atrial fibrillation. Dr. Carter ordered nuclear stress testing, which was unremarkable, and transesophageal echocardiography, which demonstrated no evidence of atrial thrombus. Dr. Carter initially planned a cardioversion at the time of the TEE, but Mr. Richardson had numerous episodes of atrial fibrillation with spontaneous conversion to normal sinus rhythm during the TEE.


    Because of Mr. Richardson's atrial fibrillation, Dr. Carter ordered intravenous amiodarone, followed by oral amiodarone loading at 400 milligrams three times a day. Amiodarone is an antiarrhythmic agent that is often sold under the brand names Cordarone and Pacerone. Dr. Carter also prescribed Pradaxa 150 milligrams twice a day as an anticoagulant agent.


    Mr. Richardson was discharged from the hospital by a hospitalist rather than by Dr. Carter. At discharge, the loading dosage of amiodarone, 400 milligrams three times a day, was continued with no recommended dosing reduction with a scheduled follow up visit for four weeks later.


    After the follow-up visit, Dr. Carter documented in his office note that Mr. Richardson was taking amiodarone 200 milligrams twice a day, when in fact Mr. Richardson was still taking the loading dosage of 400 milligrams three times a day. The 200-milligram, twice-a-day dosage is what Dr. Carter would have anticipated the discharge orders to contain. However, he did not review the discharge summary, and instead assumed the discharging physician had appropriately reduced the dosage.


    Mr. Richardson described symptoms of increasing shortness of breath and dizziness at that office visit. Laboratory follow-up for amiodarone toxicity was planned for three months later, with an anticipated thyroid function test, liver function test, and pulmonary function tests at that time. Despite these new complaints, Dr. Carter did not review the dosage of amiodarone, nor did he otherwise review the dosage with Mr. Richardson.


    Mr. Richardson had several office visits with various healthcare providers, who were not sued, over the next few months with continuing complaints of weakness, dizziness, gait instability, and imbalance. During this time, his amiodarone dosage continued at the 400-milligram, three-times-a-day dosage. This loading dosage of amiodarone was eventually discontinued about four months after it began, having been discovered by another physician who saw Mr. Richardson for frequent falls and discussed the medications with Dr. Carter.


    Mr. Richardson was admitted to the hospital approximately 10 days later with increasing debilitating shortness of breath, weakness and tremor, and focal symptoms involving his right leg, with a CT scan \ showing a subacute left frontal cerebrovascular accident. Mr. Richardson was diagnosed with pneumonitis four days later. A wedge resection lung biopsy demonstrated necrotizing bronchopneumonia, with diffuse alveolar damage. Mr. Richardson died a month later, and the autopsy found the cause of death to be necrotizing pneumonitis with multiple lung abscesses. Joining us today to discuss this case and review it further is Mister Jay. Jay, Welcome.


    Jay: Thank you, Brian. It's good to be here.


    Brian: Before we get into the discussion of the facts of the case and what happened here, why don't you tell our listeners a little bit about yourself?


    Jay: Okay. My undergraduate degree is in accounting, and I after that I took the CPA exam and passed that. So, I have a license to practice as a CPA even though I don't do that on a regular basis anymore. And then I after that, a glutton for punishment, I went to law school.


    Brian: You are a glutton for punishment.


    Jay: I am. I mean, that's too many tests for anyone to take. But anyway, I passed the bar exam, became an attorney, and so I have a license to practice both as a CPA and an attorney. But, here at State Volunteer, I practice as an attorney. I've been in the claims department now for the last 17 years, managing claims here at State Volunteer.


    Brian: As we get into this case, I wanted to start with, was there ever any type of clarification why Dr. Carter's office note showed that Mr. Richardson was on that maintenance dose of 200 milligrams twice a day at his first official visit after discharge from the hospital? Because that's where the problem really seems to lie.


    Jay: Yeah. That was a real problem with the defensibility of this case. Unfortunately, there really isn't a good reason for why that office note read the way it did. We don't really know why Dr. Carter's office notes showed the patient to be on a maintenance dosage when the patient was really still taking the loading dosage. That loading dosage is what was prescribed by the discharging physician.


    There might be a couple of reasons for it. One could be that maybe Dr. Carter just assumed that the patient was on a maintenance dosage because the time for taking the loading dosage has passed. In his plan, the loading dosage should have lasted for about two weeks and then the titration should have begun at that point. Every two weeks it would have been decreased until you got to the normal maintenance dosage.


    Brian: So he was possibly just making an assumption here that Dr. Carter had already taken care of that.


    Jay: That's right. He was more than two weeks beyond when the dosage began. We were several weeks beyond that. And so it could be that maybe Dr. Carter just assumed that the patient was on a maintenance dosage instead of loading dosage because of the timing.


    And it could be that maybe Dr. Carter assumed that the discharging physician had written a correct prescription for the maintenance dosage. Maybe he–


    Brian: Gotcha.


    Jay: –thought that this physician looked at the chart, saw that this patient was on amiodarone, and realized that he would be several weeks before he would see Dr. Carter, again and maybe Carter thought that this discharging physician just wrote the correct prescriptions going forward.


    Unfortunately, we really don't know why that note is in the chart. And like you said, that does make the case pretty difficult to defend when you've got an incorrect note in the patient's chart.


    Brian: Better communication was definitely necessary. Never assume anything. You need to go back and double check. So, with that in mind, how could better communication have really changed the outcome of this case, and what are some of the steps providers can take to really ensure that this communication is complete and these type of issues of assumption don't happen?


    Jay: Well, in this particular case, I think it would have been helpful if Dr. Carter had documented in his chart what the entire plan was. To say, "I'm going to prescribe this dosage for two weeks and this dosage for two weeks and this dosage for two more”.


    Brian: Just be more specific.


    Jay: That's right. Rather than just putting in the chart, "This is what I'm doing today-"


    Brian: Gotcha.


    Jay: ... if he had put in the chart, "My plan for the next several weeks is to do this, this and this," then I think that the communication overall would have been a lot better if he had documented that way.


    Another problem with the communication in this particular case is that the discharging physician said in his deposition that he wasn't familiar with this particular type of medication. But he still prescribed the medication for six months, saying that he assumed initial dosage by Dr. Carter was correct.


    It would have been helpful if the discharging physician had called Dr. Carter, somehow contacted him and talked to him about what this medication was all about and how it should be prescribed and that sort of thing because his physician admitted he wasn't very familiar with this type of medication.


    Before prescribing a medication that he wasn't familiar with, he could have had that kind of a conversation. He could have looked it up in the PDR or some other similar publication, rather than just discharging a patient with six months of prescriptions for medication he said that he wasn't very familiar with.


    Brian: Then on top of that, if you have the discharging physician that says that they are unfamiliar with the medication, it's not like the patient is going to go, "Oh, I know for a fact I'm not supposed to be on this much medication." They are just making the assumption that the healthcare professional is correct in this.


    Jay: Well that's right because there really aren't that many types of medications in which you titrate the dosage after a certain period of time. Most of us when we get a prescription, we're given what we're supposed to take and we just assume that it's going to be that way until the doctor says otherwise.


    They don't know that there are certain types of medications that you take in a loading dosage, and then you back off that loading dosage after a while. It was very understandable that the patient would assume, "Well, this is what I've always been taking, so I'm going to keep taking that until I'm told otherwise."


    Brian: Because the doctor knows best. Right?


    Jay: Exactly.


    Brian: How does the case illustrate the importance of the documentation of future treatment plans? I know we kind of touched on that a little bit. You had said maybe we should've had a plan. Maybe it would have been better if there had been a plan that was showed, "Okay, we're going to do this, then we're going to do this, then we're going to do this." How does this case kind of help us learn from that?


    Jay: Well, you know the thing about this case is, Dr. Carter had a plan. He knew what it was that he planned to do with this particular type of medication.


    Brian: It was just in his head?


    Jay: That's right.


    Brian: Yeah, I gotcha.


    Jay: The problem was he didn't put it in the chart. He didn't document it, and so when other healthcare providers looked at the chart, they don't know what his plan is. And so, If Dr. Carter had documented the dosage plan, including the loading dosage, and the titration plan, and what the maintenance dosage would be, then the discharging physician would have known what to do. He would have known how to prescribe a medication that he admitted he wasn't very familiar with.


    Now, I think maybe Dr. Carter could have notified the pharmacy of the plan. Although, in fairness to Dr. Carter, I think he was caught a little bit off guard by the fact that someone else discharged the patient. I don't think he was expecting that to happen, and so maybe that's why he didn't put the plan in the chart. But it would have been a better practice if he had done that just to prepare for that contingency for another physician–a hospitalist to come in and discharge a patient.


    Now, I'm really surprised when I review this case that the pharmacy didn't catch this, that the pharmacy didn't catch the fact that it was filling this loading dosage for a time period that goes beyond what you would normally prescribe for a patient on a loading dosage.


    Brian: Because you would think they would look at the dosages and go, "That just doesn't make sense," right?


    Jay: Yeah. I would think that the pharmacy would have some sort of system in place that tells a pharmacist, "Hey, wait a minute. You've been filling a prescription for this patient for X number of weeks, and he shouldn't be taking this loading dosage for this long." But for whatever reason, the pharmacy didn't catch that. They didn't have that in their system. I don't know why that wasn't there, but that's another safeguard that failed in this particular case.


    Brian: Well, we always say hindsight, you look back and you go, "Well, wow." I can see where if anybody had done something different, there were multiple opportunities for this physician to have done something different, or the pharmacist, or the discharge orders, or whatever. It's just so important that everybody really dots their I's and crosses their T's. Right?


    Jay: That's exactly right. And unfortunately, there were several places where this could have been caught, and because of that, all of the defendants in the case had to contribute to a settlement because everyone missed a little piece along the way, and the little pieces added up to a really big problem.


    Brian: Well J, as we get ready to wrap this discussion up with this case, what are some of the main takeaways? That we can look at this particular case, and we say, "This is where it all went wrong," and how can we fix that for the future?


    Jay: Well, as I said earlier, I think it's important for pharmacies to have safety nets in place to catch dosing errors like this. I think, generally speaking, pharmacies do a pretty good job of that but for some reason, it didn't work in this case. And so, maybe it's a lesson for pharmacies to learn to make sure their systems would catch something like a loading dosage had to be titrated down to a maintenance dosage.


    Second, I think it's important to document the treatment plan in the chart so that other healthcare providers can see it. When you document something in the chart, you're not just putting it there to remind yourself of what happened. You're putting it there so that all of the other healthcare providers that see this patient, treat this patient, they have an idea of what's going on. And so you're communicating with other people.


    Brian: It's a safety net, right?


    Jay: That's right, yeah.


    Brian: I mean, because it is a way to ensure the best care for your patient, even if you're not there, involved at that moment.


    Jay: That's right. Because you might be out of town, you might be seeing other patients, there could be a number of reasons why you're not available to be able to communicate with the other physician what's going on. And so, if you document that in the chart then that takes care of that.


    I think it's important for a physician to not just document what he or she is planning to do today, but if they have a plan for several weeks out, what is that plan? And they should be sure to be able to document that in the chart.


    Then the last point to make is, I think it's important for physicians who are treating the same patient to communicate well with each other, especially as in this case when the course of treatment is about to change. That is, you're discharging a patient from the hospital so he's not going to be in that setting that he's been in for the last several days, the last several weeks. He's going home.

    Everything changes when that happens, and so you've got to be sure that the physicians communicate well with each other, especially in a situation in which the course of treatment is going to change, such as a discharge from the hospital.


    Brian: You don't have the other healthcare professionals surrounding you to make sure everything is done exactly right so that discharge communication very important to write.


    Jay: Absolutely, because the patient is going to have to start taking some ownership of his own care at that point, and you want to make sure that everyone is fully informed.


    Brian: J, this has been very informative. I know for the listeners, there's going to be a lot of takeaway points that hopefully physicians can put into practice within their own practices themselves. Thanks for joining us today.


    Jay: Well, thank you, Brian, for having me. It's good to be here.


    Speaker 1: Thank you for listening to this episode of Your Practice Made Perfect, with your host Brian Fortenberry. Listen to more episodes, subscribe to the podcast and find show notes at


    The contents of this podcast are intended for informational purposes only and do not constitute legal advice. Policyholders are urged to consult with their personal attorney for legal advice, as specific legal requirements may vary from state to state and change over time. All names in the case have been changed to protect privacy.

The contents of this Podcast are intended for educational/informational purposes only and do not constitute legal advice. Policyholders are urged to consult with their personal attorney for legal advice, as specific legal requirements may vary from state to state and/or change over time. All names have been changed to protect privacy.

About our Guest

J. Baugh

J. Baugh is a Senior Claims Attorney for SVMIC. Mr. Baugh graduated from Lipscomb University with a B.S. degree in Accounting and from the Nashville School of Law with a J.D. degree. He is currently licensed to practice as a Certified Public Accountant and as an Attorney in the State of Tennessee. He has been a member of the Claims Department of SVMIC since 2000.

About our Host

Brian Fortenberry is Assistant Vice President of Underwriting at SVMIC where he assists in evaluating risk for the company and assisting policyholders with underwriting issues. He has been involved with medical professional liability insurance since 2007. Prior to his work at SVMIC, Brian worked in the clinical side of medicine and in broadcast media.