Wednesday, June 25, 2008

DID I GO THE EXTRA MILE?

It sometimes goes unnoticed that pharmacists can have a significant stake in patient care. They may find themselves involved in organizational, hierarchical, or ethical dilemmas. A Boston area pharmacist writes of a recent experience. He poses some important questions to the healthcare community:


I recently had a patient who was an 86 year-old female. She was designated for hemodialysis and as part of the process was prescribed a ceftriaxone by the Renal Physician prior to the treatment. When processing this order in the pharmacy, I noticed that a warning in the computer system indicated she was allergic to piperacillin. These 2 antibiotics are sometimes cross sensitive, and there was potential to cause harm to the patient. I called the Nurse who was taking care of the patient on the floor and asked if she knew what type of reaction she had.

I learned that she had a rash, and as such a reaction is immunologically mediated, my concern that ceftriaxone could cause harm to the patient was elevated. I asked if it was a whole body rash. However, the Nurse did not have enough information to affirm it. I then paged the MD and asked about the potential for cross sensitivity and perhaps to use another agent. The MD said that the cross sensitivity is about 10%, and he was aware of the issue. I knew that the cross sensitivity issue was not true as there is no evidence to support this and to develop a study to determine rates of cross sensitivity are generally seen as unethical. In addition not being an ID Pharmacist, I would not have a recommendation for another agent that would cover the strains of bacteria that the MD wanted to cover. I approved the order.

The next day I came in to a note that the ICU needed to have Diphenhydramine restocked. I saw that a patient (the same 86 year-old female) was in the ICU with a standing order of Diphenhydramine 50 mg every 6 hours. When I called the ICU, I asked them why the patient was receiving the medication, and they indicated that the patient had a whole body rash. I asked, “What was the causative agent?” The Nurse indicated that all they knew was that the patient was transferred from the floor during the night. The Nurse also indicated that they would need a dopamine drip to maintain the patient’s blood pressure during the dialysis session that would be going on during the morning.

I called to the floor, and they could not explain why the patient had been transferred to the ICU. A little later, I received a call from the ICU to say that the dopamine was not working for the patient and asking if we could bring a phenylephrine drip to the ICU. I said I would have one sent, but that we needed an order so we could dispense it. I took the phenylephrine to the unit and spoke to the Nurse who was helping the Dialysis Nurse set up the patient for treatment. She still did not have the order, and she told me to talk to the Renal MD who was sitting at the ICU desk.

When I asked the MD to write the order for the patient, he did not respond to me. He did not even look up, even though he was less than 10 feet away from where I was having the conversation with the Nurse. I asked him again, and he got up from the chair, walked to his left and retrieved an order sheet. He wrote the order, handed it to me, and still did not look up. I gave the infusion to the Nurse and went back to the Pharmacy.

I still do not have an answer about what happened, but I have a couple of questions.

Did I go the extra mile?

Why is there this inability for health professionals to talk openly about these events?

1 comment:

deborah said...

I'm a nurse. it bothers me that at so many points, so many people had sketchy information about the patient. As you describe it, people had just enough information to keep them going with what they had to do in "the next 5 minutes". That's a little scary. In terms of your question about going the extra mile... For me, the extra mile would have been to talk to the patient about the risk of a reaction and involve that person in the process. Involving the patient is always the extra mile not taken. Thanks for sharing your story.

Miss Deb

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