There are some scenarios that may send red flags up that harm to a patient occurred due to a medication. The simplest (but unfortunately, least likely) scenario is when a healthy patient, taking no other medications, says “I just started taking this medication and as soon as I started taking it, something went wrong”. And, the “what went wrong” part has been well-documented in the medical literature. But harm from medications is not usually that easy to sort-out.
Medication adverse events are not always obvious, even to the trained medical professional. There are reasons for this. A patient may have medical conditions that cloud the picture of an adverse drug reaction. There may have been a medication error (that is, wrong drug, wrong dose, or wrong patient) but it went unnoticed. Or, the medication error was noticed but not reported by the health care provider for fear of retribution or poor documentation.
As a toxicologist, the first thing I am looking for when reviewing medical records is if any of the drugs given to a patient could have contributed to the patient’s medical condition. And of course, if a medication harmed a patient, how can this harm could have been prevented.
For attorneys, there are the “top 5” things to think about when reviewing details of a medical case, which may or may not be a medication-related case from the get-go. Of course, a toxicology or other medical expert may be at your fingertips, but here are some tips for attorneys before that step is even a thought:
- Did a patient receive too much medication?
The dose makes the poison. As a toxicologist, this is one of my favorite adages. There is so much truth to it. Yes, a drug or even a chemical can have a lot of dangerous effects associated with it. But the question becomes, how much was the patient actually exposed to? That is not always easy to answer. In the case of a hospitalized patient, we can only go by what is documented in the chart and we hope that the documentation is accurate. In the case of a patient who returns home with prescriptions, we don’t know with certainty if the patient was taking the drug as prescribed. Or, perhaps the patient was taking a drug not even intended for them.
- Was a medication appropriate for a patient?
Even a “normal” dose of a drug may be harmful to a patient. How can this be? Didn’t we just ascertain that the dose makes the poison? Some other scenarios can be at play here. For example, were there other medical conditions that made a certain drug less tolerable and more toxic to a particular patient? Were there medications that interacted with one another, intensifying the effect of one or more of the drugs or extending the time the drug stayed in the body? As an attorney, don’t write off a possible medication adverse reaction just because the dose was acceptable.
- The dose of the drug was fine. Or…was it?
What is an acceptable dose of a drug? Sometimes the answer is very patient-specific. There are drugs with very narrow margins of safety (drugs like lithium, phenytoin, warfarin). That is, a little bit off from an acceptable dose can lead to harm. Some drugs are based on the patient’s weight. Is there a weight documented in the medical records? Or was an “average adult” weight used to calculate the dose? Did the patient change their diet or have a recent gastrointestinal illness? This area is a little trickier and probably warrants a call to a toxicology expert.
- Were any antidotes included on a patient’s drug list? If so, why was it used?
An antidote is used to reverse the effects of a drug. An attorney may not know why an antidote was used when it is encountered in a medical record. For example, was it simply to reverse the effects of anesthesia? Or was a drug given in an excessive amount and now its effect needs to be reversed by an antidote? Or did a patient have an adverse reaction to a drug that needs to be treated? Examples of antidotes are naloxone and flumazenil. It’s helpful to know why each and every drug on a medical record was used. You may be surprised what you find out.
- I see drug levels. Why are they here and what do they mean?
Keep an eye out for drug levels in medical records. Why were they performed? Was it for routine monitoring of a patient or was it because there was an adverse medication event? Interpreting drug levels is challenging. Drug levels do not always correlate with how sick a patient is, or will become. Drug levels are measured in different ways and the interpretations of these tests is a science in itself. Keep your radar up when you see drug levels in a medical chart. But discuss them with a medical expert to help you connect the dots. Connecting the dots is what experts are there for.
Most often, I am asked by attorneys to review cases that involve the living. But at times, I am asked to review cases that involve the dead, and the question becomes: what happened before death? Specifically, what was the role, if any, of the drugs/chemicals/toxins found in the decedent’s body according to postmortem toxicology testing? Examples of such cases include those involving death following drug delivery, medication-related deaths, and fatal accidents (motor vehicle or workplace) following drug or alcohol use.
When it comes to drugs, it’s not straightforward (and at times, not possible) to determine what amount of drug was used prior to death. In my CLE talk “Postmortem Toxicology for Attorneys: What Can Dead People Tell Us?”, one of my main take-home points is that if all you have are postmortem drug levels, then all you have are … postmortem drug levels. I know, that sounds simplistic. But, it sums up the main point I want to make regarding such levels. There are published tables of postmortem blood concentrations for numerous drugs in the medical and forensic literature. The existence of such tables have created the expectation that one can simply look up drug levels on these tables, compare them with those from a postmortem toxicology report, and voilà! … determine if the drug was taken antemortem (before death) in a therapeutic, toxic, or fatal dose. Those tables have their time and place. However, they are not meant to be used in isolation but rather simply as the starting point of a toxicologic investigation. “User beware”.
There are numerous variables that can influence postmortem drug levels, making these published tables only a reference source. As a toxicologist interpreting postmortem drug levels, I want to hear a “story”. This story should include as many of these chapters as possible: the decedent’s medical history (eg, medical conditions, medication history, drug abuse history), information from the scene (eg, drugs, drug paraphernalia), witness accounts (what was the decedent’s behavior prior to death?), police reports, autopsy findings, when the postmortem samples were collected, the location from which the postmortem samples were collected, and the circumstances of death. There of course can be other chapters to this story (these are just a few). But I list these to illustrate that reliable interpretation of postmortem drug testing results hinges on more than just drug levels.
It’s not everyday that I get a room full of attorneys, who after a long day, want to learn some toxicology. But this week, I had not only a full room, but an engaged audience ready to learn about naloxone. This talk covered questions including: What is naloxone? How does it work? What are the reasons behind the opioid epidemic and how does naloxone fit in? How can this information help me with opioid-related cases (and how do I know if my case involves an opioid to begin with?) All these questions, and more, were covered in this 1-hour CLE course at Jenkins Law Library in Philadelphia.
I had the pleasure of speaking to an engaged group of attorneys this week at the Jenkins Law Library in Philadelphia, PA. I gave a one-hour continuing legal education (CLE) talk on how attorneys can sort through the details of medical charts to identify and understand any possible “medication misadventures”. What are medication misadventures anyway? How do medication misadventures occur? What are some red flags to look for when going through medical charts? What are some valuable sources of drug information for the non-healthcare-professional? If you have an hour (or just want to skip around the video below) you can get these, and perhaps many more, questions about medication safety answered.
Not every antidote in toxicology gets the spotlight like naloxone does. And why is that? What is special about naloxone and what is it an antidote for anyway? I recently published an article for the attorney audience through the American Bar Association and shed some light on this prescription drug and the fight that it’s trying to win. It doesn’t stop there though. I’m taking the naloxone conversation on the road to speak to attorneys and pharmacists at the 2016 American Society for Pharmacy Law annual conference next month.