The case went to trial and ultimately hinged on the testimony of the medical experts and the documentation in the patient’s chart. The plaintiffs claimed that the patient was not competent to understand the directions and that the clinicians should have contacted a family member as well. However, the records showed that the patient had managed dosage changes with no problem in the past, even when it involved cutting pills in half. It would not have been appropriate to contact the family because the patient had not given permission to do so, and her medications were confidential information.
The plaintiffs claimed that an earlier follow-up appointment should have been scheduled after Mrs A’s dose was changed, but this would not have affected the outcome, and the experts admitted that a 7- to 14-day window for retesting INR was fine.
The plaintiffs then argued that the dosage instructions on the 5-milligram warfarin bottle said, “take daily” and on the new 4-milligram bottle said “take on Monday, Wednesday, and Friday,” leading to the probability that Mrs A accidently took both a 5- and 4-milligram pill on the Monday she picked up the prescription. They argued that Ms B should have specifically told the patient not to take the 5-milligram pill on those days.
The defense experts, however, testified that Ms B had met the standard of care by clearly explaining the change in dosage, and that it was being lowered (not raised), and having the patient repeat back the instructions, which she was able to do.
After deliberating, the jury ultimately found the defendants not liable.
Although you cannot always protect yourself from being sued, you can increase your odds of not being found liable by taking good notes, as the clinicians did here. The notes documenting the various changes in warfarin dosage, combined with new INR numbers showing that the patient was taking her medications correctly during the past year, set a foundation that the patient was competent, able to understand directions, and able to adjust her dosage. The documentation by Ms B of the patient’s last warfarin adjustment made it clear that the patient understood the change and was able to convey the new directions back to the clinician.
Dosage changes, particularly in patients with chronic diseases, sometimes need to be made over the phone. While face-to-face conversations are always preferable, they cannot always happen. If you need to change a dosage via the phone, be sure that the patient understands the dosage change, can recite the change back, and understands the underlying reason for the dosage change. Do not rush these conversations, and consider asking the patient to write down, then read back, the new instructions.
Ms Latner, a former criminal defense attorney, is a freelance medical writer in Port Washington, NY.