Is this negligence?

What is the name of your state? New Jersey

I wrote some months ago about my father who had undergone brain surgery and was given Dilantin. Two prescriptions from different doctors dated the same day from the same medical center were filled by the pharmacy at the same time. One prescription was for Dilantin 300mg taken once daily and the other was for Dilantin 100mg taken 3 times daily. My father was taking a total of 600mg a day. He then became toxic and had to be hospitalized. The doctor at that hospital said he had been taking way too much Dilantin. I have since learned that the pharmacist filled the prescriptions correctly (the medication, directions, strength) based on the what the doctors' prescribed. But was the pharmacist negligent in not checking with either of the doctors that the dose was too high? Thank you.

[ellencee]

ADULTS


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Standard Daily Dosage

If you have not had any previous treatment, your doctor will have you take one 100-milligram Dilantin capsule 3 times daily to start.

On a continuing basis, most adults need 1 capsule 3 to 4 times a day. Your doctor may increase that dosage to 2 capsules 3 times a day, if necessary.

Once-A-Day Dosage

If your seizures are controlled on 100-milligram Dilantin capsules 3 times daily, your doctor may allow you to take the entire 300 milligrams as a single dose once daily.


**This is all I am going to say--why should the pharmacist question the prescriptions when two 100 mg capsules taken three times a day equals 600 mg a day and that is what your father's prescriptions totalled? It isn't a dosage out of the range of recommended dosages.

LOL ! ! Now that you have stated that "Two prescriptions from different doctors dated the same day from the same medical center were filled by the pharmacy at the same time. One prescription was for Dilantin 300mg taken once daily and the other was for Dilantin 100mg taken 3 times daily", either the doctors involved in your dad's care or someone in that pharmacy has made a boo boo, in my opinion.

The pharmacist may have indeed filled each Rx correctly, but the problem may lie in the fact that your dad's Dilantin should not have exceeded 300 mg per day whether it was taken all at once or three times a day (but that it severely exceeded that because he received two Rx's from two doctors).

If the two doctors involved prescribed Dilantin independent of the other for this post op condition and the dose was not supposed to exceed 300 mg a day, there's a problem and a liabilitly issue on the MD and pharmacists shoulders.

Think of it like this: A pharmacist receives five Rx's from five different doctors on the same patient for the same drug and fills all of them and gives them to the patient; the patient gets the print out on all Rxs, reads it, follows the instructions on the print out and the five bottles; overdoses, and dies. Do you see the potential liability that falls on the doctors and the pharmacist? The doctors are responsible to know what other doctors have done with respect to treatment. They find out through patient history and chart / medical record reviews. Your dad was a post op patient on Dilantin. He wasn't out doctor hopping, attempting to receive drugs fraudulently. The pharmacist should check on Rx's received from two different docs on the same drug.

Here's some pretty good reading.

[url]http://www.amda.com/caring/march2002/druguse.htm[/url]

Good luck.

hmmbrdzz

The defense lawyers are going to jump on your father. Why did he go to TWO doctors for the same prescription?
Patients often go to two or three or four doctors for presciptions for dope, but for dilantin? You father's case will be lost.

Rlorx, you have given absolutely no reason for me to think your dad was doctor hopping for dope. Your dad could very well be a patient who who did just as he was instructed to do post-op brain surgery. If your dad suffered injury on account of taking too much Dilantin due to physician and/or pharmacy negligence, it could very well be a case.




hmmbrdzz

[ellencee]

Well, color me blind! It didn't connect in my brain that it was two different doctors. That changes things a little, if we assume it wasn't two doctors from the same practice and it wasn't an intentional writing of the second prescription to use the 100mg tablets for titering the dosage above the 300 mg tablet even if the MDs were in separate practices. It isn't unheard of for MD #2 to say, keep the Rx from MD #1 and add this RX and instruct the patient on how to take the medication.

The pharmacist is used to seeing Dilantin prescribed in a manner for titrating a therapeutic dosage, even in the presence of two doctors writing prescriptions.

JS is absolutely correct, in my opinion. The poster's father is responsible for his own actions of taking two prescriptions for the same medication; and, a good defense attorney will make the dad look totally responsible for over-medicating himself.

Well smack me right between my dumbass eyes. LMAO! I’m not believing what I’m reading. It's no wonder I wonder about some things sometimes.

There's not a pharmacist I know of who would not stop dead in their tracks at a Dilantin Rx from two different docs (especially one that equaled 600 mg of Dilantin per day), nor a nurse I have ever worked with who wouldn‘t stop dead in their tracks if the patient's MRA reflected Dilantin 300 mg, one tab q d and the next order reflected Dilantin 100 mg, one tab p.o. t.i.d.. I would shoot myself before I EVER gave a patient 600 mg of Dilantin per day without calling everybody who was involved in the transcription of that order -- from the two doctors who had prescribed it, to the pharmacy who had filled the order, to the nurse who had transcribed the order onto the MAR, so on and so forth. Whether or not I submitted a medication error report would depend solely if a medication error had occurred yet (and I'd bet my last dollar that if a 300 mg tab had already been given that morning to a post op brain surgery patient, I would have been the idiot who would have made a medication error had I given another 100 mg, or worse yet if I had given a 300 mg tab at bedtime after the patient had received three 100 mg doses that day).

Ellencee, I'll have to say that I'm totally dumbfounded as to your logic on this one and don‘t know what to say about it. And Jack, for all I know you don‘t know jack about Dilantin (regardless of your web site, which I just saw yesterday and quite frankly was perplexed by it after reading your input here). You have stated here “the defense attorneys are going to jump all over your father". Let‘s look further at that input. You gather no information, you imply this post op brain surgery patient was doctor hopping for dope, you ask one question about why two doctors were involved, and then -- without getting an answer -- you conclude "the case" will be lost. What kind of evaluation and conclusion is that? What's it based on? Please do tell why you believe Dilantin 600 mg q d was the appropriate dose, why you believe it was a loading dose, who prescribed it, what the pharmacist did prior to filling it, and how you have determined that this post op brain surgery patient, who wound up toxic from Dilantin and back in the hospital, was doctor hopping for dope, who is the one who made all the errors, and how the pharmacy and doctors had nothing to do with this toxicity. I'm not trying to be "disrespectful", but rather I feel professionally bound (and able) to challenge you and request your explanation. Plus, I’d like to know if your malpractice books are worth buying.

Rlorx, based on what you've said about your dad and the directions on each bottle, this was not a loading and titrating dose of Dilantin. If your dad got two bottles from the same pharmacy that had one prescribing doctor on one bottle and different prescribing doctor on another bottle (and the doses combined equaled 600 mg per day of Dilantin), your dad was not the only one who is to blame for his toxicity (and may, in fact, be blameless). 600 mg of Dilantin per day = eventual toxicity.
You should find out why your dad became toxic. If your dad suffered injury on account of the toxicity, you should get advice on any potential claims your dad might have from an attorney.


Best of luck.


hmmbrdzz

Ladies: I did not jump to any conclusion., As I said, malpractice was done, and no question about that. What I said was that this case will be lost. It will not be lost on the "merits", it will be lost because the insurance companies will attack the patient and will end up winning because someone, either the patient or his family should have seen that the patient refuse the second prescription. Two prescriptions on the same day for the same medicine?
I have watched many insurance company lawyers destroy an injured patient because that is their ONLY defense. Insurance companies will pay their lawyers more than what they would have paid out had they settled the original complaint. They do this because they do not want to establish in people's minds that they will pay for mistakes. They are not in the business of protecting patients, only their reserves.
Dilantin and its proper dosage is not the issue in these cases. No matter what medicine is prescribed, that two doctors who should have been in contact about this patient ordered medicine without consulting the other is the major malpractice. The pharmacist also was at fault and should be sued because had he been alert (possibly by maintaining a drug profile for this patient) he could have called both doctors and corrected the dosage. No one has to know the pharmaceutical implications, only that the pharmacist has a responsibility in this case.
Don't worry. I am not going to argue this case anymore.

I didn't see anything about "malpractice was done". Had I seen that or thought it was implied, I would not have asked for your clarification on your response. Thanks for giving it.




hmmbrdzz

[ellencee]

h'bird
First, I don't have all of the facts, just this tiny bit of information.
Secondly, it is entirely possible for this to have occurred and there to be no negligence.

I'll give you two examples (each) from a patient's perspective and from my professional perspective:

Patient persepective--#1--patient goes to doc #1 and doc #1 gives RX for dilantin 300mg 1/qd, same dosage as pt has been on for several months. doc #1 sends pt over to see doc #2 for reason xyz and doc #2 determines pt needs to titrate the dosage above 300mg per day and gives the pt an Rx for 100mg tablets three times a day and provides the patient with instructions, etc. Pharmacists fills Rx and nothing has been done incorrectly.

example #2--patient goes to doc #1 with concerns about seizure activity and concerns that 300mg tablet qd isn't doing what he thought it would. doc #1 says there is no problem with medication or dosage. pt. goes to doc #2 and says he doesn't like what doc #1 says about the medication being OK. doc #2 says, well, let's see what up'ing the dose does; we can increase the dosage with 100 mg tablets; here's an Rx for 100mg tablets 1/tid; see me in X days for labwork,etc. Pharmacist fills RXs and no negligence occurs.

Professional perspective #1--As a nurse, if the doctor wrote the orders for Dilantin 300 mg qd and Dilantin 100mg tid for dosage titration, I wouldn't question it. I'd do what he said and monitor the patient for adverse symptoms and monitor the blood levels as ordered. In this example, the MD would have communicated with me either in person or through documentation such as MD progress notes.

#2--If as a nurse providing Home Health services, I had a patient with these two Rx, I'd assess for adverse symptoms, verify when the last Dilantin level was obtained, obtain a seizure 'history' from the patient, and get whatever orders I needed for labwork, etc. from the doctor.

In neither professional situation would I assume that the MD was incompetent or that the pharmacist was incompetent.

As I stated months ago, this case is defensible (refer to the professional, published information on Dilantin that I copied and pasted to this poster). All the defense has to do is get the same, easily accessible professional literature on the medication and use those medical/drug facts as its defense. You and the poster must understand that the pharmacy will defend against the accusation of negligence.

JS has expertly and with experience stated that the defense is going to make the man look guilty, not the pharmacist.

Now if the man, who obtained these two doctor's opinions and prescriptions from each and then had these two Rxs filled and swallowed the pills, wants to go into court, then by all means let him find an attorney and march himself into court and lay his cards on the table and let whatever happens, happen. That is soley his decision.

I started to offer to call my uncle, who has a doctorate in 'pharmacy' or call my former brother-in-law, who also has a doctorate in 'pharmacy', and ask one of them. There isn't any need for me to that--call WalMart's pharmacy or KMart's pharmacy or CVS or Revco, or whatever pharmacy you choose (this goes for the poster, too) and ask the pharmacist. Who knows, each and every one may say that in no way would they have filled the Rx, then JS and I can be fairly criticized for our opinions. You can also do a simple search for medication, Dilantin, and obtain your own copy of the professional literature that I have posted. There are several drug references easily available and each of them states the same thing--that a total of 600mg qd may be required for some patients. What's a pharmacist to do? refuse to give the patient the dosage required to control seizures because most people don't require 600 mg and to hell with the fact that 'this' patient does?

I'm with JS--I'm through arguing this case. Hopefully, the poster will find someone to hold accountable for her father's actions without it being her father! Then, all will be well with the world for at least one more day.

Rlorx: It would take an idiot of a consulting physician to tack additional Dilantin dosing onto an existing Rx of Dilantin 300 q day written by the referring physician. To do something like that would be practicing way below the standard. If the consulting doctor did do something like that, the pharmacist is liable to clarify the two orders (question them). It's a very simple concept of practicing "within the standard of care". Fundamental as it comes.

600 mg of Dilantin from two prescribing physicians is a waving red flag (one sticking WAY up in the air). If anyone involved in your dad's care waited until toxicity symptoms appeared before questioning an order of 600 mg of Dilantin from two prescribing physicians, they were practicing way below standard (negligently). If the pharmacist didn't clarifiy the accuracy of the two orders, then he has practiced negligently. What any attorneys do or don't do / say or don't say will be up to them when and if they assist you. Best of luck again.


hmmbrdzz

Oh my Dear Lord. Is this not funny or what? When I read the first few words, I thought "who is this getting ready to call me a bi***?"

I think I"ll pass on the URL this jerk provided and instead just pass this threads URL onto our administrator for "review"!

From the looks of my mail box this a.m., it looks like this person has managed to get his message out on quite a few threads.
Takes all kinds.


hmmbrdzz