Alleged allergic reaction

Clinical presentation
A 39-year-old man presented to the emergency room with a serious response to a recent puncture wound on his back.

Physician action
During the course of the hospitalization, he received Ancef, which was discontinued due to an adverse reaction. The patient was then started on Vancomycin, but developed a reaction to that medication. The Vancomycin was discontinued, and the patient was placed on oral Augmentin with instructions to continue this regimen when he was released from the hospital.

After being discharged from the hospital, the patient began follow-up treatment with his internal medicine physician (the defendant in this case), who at that time continued the Augmentin. The physician saw the patient again 11 days later. At this visit, the physician gave him an injection of Rocephin and placed the patient on oral Ciprofloxacin. This treatment was continued for five days, at which time the physician ordered home health care to administer the Cipro by infusion through a PICC line. The patient presented to another emergency room with an apparent reaction to the IV Cipro. The Cipro was discontinued after a consult between the emergency department and the internal medicine physician.

The patient returned to the internal medicine physician two days after this emergency room visit. The doctor ordered Vancomycin to be administered every six hours by ambulatory infusion pump. The following day, the patient’s wife took him to see the physician because of nausea and vomiting after the Vancomycin infusions. The physician reviewed infusion protocol for Vancomycin and prescribed Reglan to be given prior to the infusions to reduce the nausea and vomiting. The patient was found dead in his home that evening.

Allegations

The plaintiffs alleged the patient died as a result of a cardiac arrhythmia caused by a histamine release due to an allergic reaction to Vancomycin.
Record fabrication and alteration

Legal principle
In this case, proximate cause was one of the main issues to address. TMLT experts felt this case was medically defensible, and were willing to testify that the internal medicine physician did not cause the patient’s death by prescribing medication the patient was allergic to. The consultants believed the patient died as a result of a coronary artery spasm totally unrelated to any treatment by the internal medicine physician. The plaintiffs, likewise, had retained experts to support their theory of liability. While this case was defensible from the medical standpoint, it was severely compromised by an alteration of the patient’s medical record by the defendant physician. During the physician’s deposition, the plaintiff’s attorney presented different versions of the patient’s medical record. Long before the possibility of a malpractice claim was known, a copy of the medical record was sent to the plaintiffs’ counsel, unbeknownst to the defense, in connection with a workers’ compensation claim filed by the patient due to the puncture wound. Once the physician was in receipt of the malpractice claim, he produced a dictated version of the medical record to the defense council. Handwritten notes existed as well and the record had suspicious entries throughout. The copies of the medical record provided before the physician was notified of a claim and the copies of the medical record provided in defense of the claim were significantly different. The existence of more than one version of the medical record significantly undermined the physician’s credibility.

Disposition
This case was settled in the low six figures on behalf of the internal medicine physician. The physician’s alteration of the medical record was a major factor in the settlement of this case.

Risk management issues

Patients tend to be poor historians; therefore, it is imperative for physicians to obtain medical records from hospital admissions. It is recommended that physicians review the records to ensure they are aware of what took place in the hospital. To demonstrate these records have been reviewed, it is good practice to initial and date the copies obtained or document in the medical record that they were reviewed.
Medication errors continue to account for a significant percentage of indemnity paid claims. The Physician Insurers Association of America conducted a data sharing project, which found medication errors to be the fifth most prevalent misadventure. At TMLT, medication errors are the fourth most prevalent misadventure. In many cases, the patient or pharmacy may catch the error, but often they do not. When prescribing medications, it is imperative to review the medical record as well as question the patient regarding any known allergies or sensitivities. Records must be continually updated regarding new allergies and sensitivities, and this information must be entered in all places where allergy documentation is routinely found. The use of a medication flow sheet is recommended to serve as a quick reference for allergy documentation. Placing the date beside the allergy will help indicate when the patient was questioned about allergies to medications.
Altering the medical record seriously jeopardizes a physician’s credibility. Upon reviewing the medical record when served with a notice of claim or lawsuit, physicians may be tempted to add information they believe will assist in their defense. While the information itself may be accurate, the addition of such information after the event is always detrimental to the defense of the case. Plaintiff’s attorneys will use this information to discredit the physician by suggesting that he/she did something wrong and are trying to cover for it. Experts have advanced technology to pinpoint when an entry was made. In many cases, this is not necessary since most alterations can be seen clearly with the naked eye. The message is clear: if a physician alters medical records, this will be discovered. While there may have been no breach of the standard of care, situations like this are difficult to defend at trial and frequently result in settlements out of court. It is recommended, upon notice of a claim or lawsuit, that the medical record be placed in a secure location to protect the authenticity and avoid any possible temptation to alter information.