Features

Failings in the system: a case study

One of the misconceptions about root cause analysis (RCA) is that its only purpose is to look at the primary cause of an incident. In fact, RCA looks for all the interventions after an incident or error that might have been an opportunity to rectify the problem.

The case study in this article involves a patient who was prescribed two different beta-blockers for more than a year. In that time, a number of health care professionals had the opportunity to identify the error and stop one of the beta-blockers but failed to do so. As a result, the patient experienced significant side effects and considerable costs were incurred in investigating his symptoms.

Background

Mr M is a 74-year-old who had an unremarkable medical history until May 2003 when he went to see his GP with joint pain, which was diagnosed as osteoarthritis. Indometacin 75mg od was prescribed but this was changed to rofecoxib 12.5mg od a few months later. (Readers may think the cyclo-oxygenase 2 selective inhibitor could have contributed to the patient’s subsequent cardiac problems but this is beyond the scope of this article.) Later still, rofecoxib was replaced with co-codamol prn. Mr M also suffered from gastrointestinal reflux.

Sequence of events

September 2004, beta-blocker prescribed Mr M came to the practice with chest pain and, as is standard procedure, was referred to a rapid access chest pain clinic for assessment. He was subsequently prescribed: nebivolol 5mg od, aspirin 75mg od, simvastatin 40 on and ramipril 2.5mg od. I believe the initiation of nebivolol was the first error in this case; it is an expensive non-formulary beta-blocker and the patient’s notes reveal no justification for not using a formulary drug.

Leaving the cost implications aside, the use of a less common drug may have contributed to the addition of the second beta-blocker — nebivolol was presumably not recognised as a beta-blocker by the later prescriber. Unless there is clear clinical need, formulary drugs should always be used first line; they are chosen for their evidence base and cost effectiveness and, perhaps what is not so often appreciated, they are more widely recognised.

March 2005, nebivolol stopped Mr M had a stent fitted to treat unstable angina. Following the procedure, nebivolol was stopped (it was not on the discharge medication list) but it is probable that it was not deleted from the practice computer.

May 2005, second beta-blocker added Mr M’s notes indicate that bisoprolol 2.5mg od was prescribed three months after the stent, for chest pain attributed to angina on exertion. It is unclear who made this addition, but this is the first clear cause of the problem because Mr M still had in his possession an old repeat prescription request form, which listed nebivolol. Although it is common when stopping a drug (ie, nebivolol) to delete it from the practice list of current drugs, it is less common to ensure that the patient only has up-to-date forms for ordering repeats.

When the bisoprolol was initiated, Mr M should have been asked to destroy all old repeat request forms. Because this was not done, Mr M was able to order both nebivolol and bisoprolol and it appears that from May 2005 he was taking two beta-blockers.

September 2005, opportunity 1 Mr M was admitted to hospital with chest pain. The diagnosis was that the pain was non-cardiac and probably musculoskeletal. The medication list on admission contained nebivolol and bisoprolol and no procedure on admission picked this up. There was also a lapse in the discharge procedure: the two beta-blockers are listed on the discharge form. My understanding of the secondary care procedures is limited but it is usual for a pharmacist to sign off the discharge medication form. So, at least one health care professional, the discharge pharmacist, was in a position to intervene and correct the error. At this point, Mr M was taking:

Aspirin 75mg od
Nebivolol 5mg od
Clopidogrel 75mg od
Ramipril 5mg od
Bisoprolol 2.5mg od
Isosorbide mononitrate 20mg bd
Simvastatin 40mg on
Quinine 300mg on
Co-codamol 30/500mg prn

October 2005, opportunity 2 When Mr M was admitted to hospital with chest pain in September 2005, he was found to have gastric angiodysplasia, which was treated with Argon plasma coagulation. The treatment was routinely followed up a month after. Nothing of note was recorded during the follow up, but the main issue is that the discharge letter from the consultation listed all Mr M’s current medicines, including the two beta-blockers. Again, the co-prescribing was not picked up by anyone.

November 2005, opportunity 3 Mr M had continuing chest pains and underwent cardiac imaging (a “Myoview”). It is unlikely that a pharmaceutical history was taken during the Myoview examination — no list of medication was made on admission and the discharge letter did not contain a medicines list. Mr M continued taking the nebivolol and bisoprolol.

May 2006, opportunity 4 Mr M, occasionally dizzy, tired and bradycardic, and with a BP of 100/40, had a perfusion scan. This showed no inducible ischaemia, suggesting that the continued chest pain was not coronary. Again, the discharge letter did not contain a list of current medicines and a fourth opportunity to question the two beta-blockers was missed.

Communication between primary and secondary care seems to have been less than ideal and a clear, accurate system of communicating current medication might have picked up the error.

June 2006, opportunity 5 It was not until I invited Mr M for a medication review that the two beta-blockers were noted and a slow monitored withdrawal of nebivolol was initiated.

Conclusion

At least seven key events that may have contributed to, or where it might have been reasonable to have identified the error have been established. It is not possible from the patient’s notes to identify all the primary and secondary care personnel involved, but the purpose of RCA is not to apportion blame. Rather, it is to determine the original cause of a problem and analyse the sequence of events, identifying where the error could have been corrected.

In addition, prescriptions being dispensed in primary care should have resulted in a call to the prescriber. Furthermore, this situation could have prompted the community pharmacist to undertake a medicines use review.

There are a number of key messages from this case. The communication between primary and secondary care, with particular regard to current medication, needs to be improved. As a minimum, secondary care providers must always be assured that they have an accurate up-to-date medication record for a patient. In addition, the number of missed opportunities for intervention from both primary care, secondary care and community pharmacists means we must question the effectiveness of current checks and safeguards.