Improper prescribing following surgery
A 43-year-old man came to the ED with sudden epigastric pain radiating to his back with severe nausea and vomiting.
by Wayne Wenske, Senior Marketing Strategist, and
Emma Louise, MS, CCC-SLP, Risk Management Representative
Presentation
A 43-year-old man came to the emergency department (ED) on August 21 with sudden epigastric pain radiating to his back with severe nausea and vomiting. The pain was described as sharp and stabbing.
His lipase (30) and creatinine (0.81) levels were within normal limits. The patient was given morphine, and his pain subsided. He was instructed to follow up with his primary care physician (PCP).
On August 24, the patient went to his PCP who performed an ultrasound of his gallbladder and found multiple small stones and sludge. The patient was sent back to the ED.
Physician action
The patient was seen in the ED by General Surgeon A, who took the patient to surgery that day. Upon admission, the patient’s bilirubin (2.2) and liver function enzymes were elevated. His lipase was still within normal range. General Surgeon A prescribed a five-day round of ketorolac for the patient’s pain.
A laparoscopic cholecystectomy with intraoperative cholangiogram was performed, and a common bile duct stone was identified.
General Surgeon B performed an endoscopic retrograde cholangiopancreatography (ERCP) concurrently, while the patient was still under anesthesia. An extraction of the identified common bile duct stone was completed.
Over the next two days in the hospital, the patient continued to experience epigastric abdominal pain, nausea, and vomiting, and was placed on a clear diet. His urine output dropped to 400cc.
General Surgeon A noted that the patient was experiencing post ERCP pancreatitis with lipase levels over 4000 and amylase levels over 1000. The patient was given intravenous fluids, antiemetics, and pain medication including large and frequent doses of morphine. He was also continued on ketorolac.
On the patient’s fifth day in the hospital, the patient’s pain, nausea, and vomiting were still present, and he reported that the ketorolac was not providing any relief. He also reported “spots” in his vision. His urine output was 1150cc.
The hospital pharmacy’s automated unit dose distribution system cancelled General Surgeon A’s ketorolac prescription at the fifth 24-hour period. The surgeon ordered another round of the medication without blood work. On this day, the patient had zero urine output, visible swelling, and had gained more than 20 pounds from his admission weight.
On August 31, the patient’s bloodwork showed elevated creatinine (12.25) and anuria. General Surgeon A stopped the patient’s ketorolac and consulted with Nephrologist A. Nephrologist A noted that the patient had acute kidney injury likely due to the nephrotoxic effects of ketorolac.
On September 3, the patient was transferred to another hospital for hemodialysis. He received hemodialysis for seven days. Upon discharge from the second hospital, the patient’s creatinine level was 3.97, lipase was 231, and bilirubin was 0.6. By the end of October, he had complete recovery of renal function and his visual disturbances were resolved.
Allegations
A lawsuit was filed against General Surgeon A for prescribing ketorolac beyond the five-day safe dosage limit, causing kidney damage and impaired vision.
Legal implications
General surgeons who reviewed this case for the defense were critical of General Surgeon A for not following the patient’s electrolyte panel daily. They expressed that had this blood work been done, the elevated creatinine would have been noticed and the ketorolac stopped earlier, preventing acute renal failure and the need for hemodialysis.
General Surgeon A did not document his reasoning for continuing the medication past the five-day recommended dosage and did not monitor its effects on the patient’s condition. The reviewing surgeons agreed that it was a deviation from the standard of care to not monitor the patient via lab work. It is well known that long-term use of ketorolac can cause kidney damage or bleeding.
No documentation exists of an appeal from the hospital’s pharmacy regarding the second prescription of ketorolac. One reviewing surgeon questioned why there was no discussion at any time during the patient’s admission between General Surgeon A and the pharmacy regarding this prescription.
Disposition
This case was settled on behalf of General Surgeon A.
More on medication errors.
Risk management for general surgeons.
Disclaimer
This closed claim study is based on an actual malpractice claim from Texas Medical Liability Trust. This case illustrates how action or inaction on the part of the physicians led to allegations of professional liability, and how risk management techniques may have either prevented the outcome or increased the physician’s defensibility. This study has been modified to protect the privacy of the physicians and the patient.
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