Miscommunication At Rehabilitation Facility Causes Fatal Overdose


Addiction Medicine Expert

This case involves a young small business owner with a history of alcohol abuse who had been checked into a rehabilitation clinic. One night during her first week at the clinic, the patient developed severe difficulty breathing and was immediately taken to the hospital. At the hospital, the patient was given a psychoactive drug in the presence of a representative from the rehabilitation facility. The next day, the hospital administered the patient’s dose of medication and the patient returned to the rehabilitation facility. It was alleged that the hospital did not communicate to the rehabilitation facility staff that the patient’s daily dose of medication had already been administered. Upon the patient’s return, the staff of the rehabilitation facility gave her an additional dose of medication. The patient began slurring her speech and convulsing, but the staff allegedly did nothing to help the patient. She fell into a coma and passed away shortly thereafter. An expert in addiction medicine was sought to discuss the standard of care for administering outside medication to rehabilitation patients.

Question(s) For Expert Witness

  • 1. How often do you treat patients for alcohol abuse?
  • 2. What is the standard of care for documentation of any outside medication given at your facility?

Expert Witness Response E-168190

I am board certified in both family medicine and addiction medicine and I maintain a small private practice treating addiction. I have been involved in the process side of things, setting policies, teaching, advocating and acting as a subject matter expert for a large health plan. Because my clinical activities are geared directly to alcohol/drugs, I have seen thousands of patients in both acute hospital settings and in outpatient settings at my clinic. Alcohol and opioids are the two most common substances I treat, followed by benzodiazepines and stimulants. The standard of care for giving medications at most licensed facilities includes a print out of a medication reconciliation (ideally in the language of the patient and legible for visual impairment barriers) and possibly the prescription itself if it is not electronic. Depending on the setting, the patient may receive a discharge packet as well. This is then used to reconcile the medications when there is a transition of care. However, there is sometimes variability in what the patient actually receives due to the electronic medical record or internal protocols. The waters get murkier if we are talking about medications dispensed during the course of the treatment for cases in which those medications are not intended for aftercare prescription. A patient may receive many medications to be stabilized but those medications are then discontinued as the patient transitions out of that level of care. This can take some investigating on the part of the acceptors of the patient on transfer. There is more to that and I would have to see the specifics. Transitions are undoubtedly where mistakes are made. How and where the transition happens, and to what level of care, is what may support whether it would be considered neglect/malpractice or outside of standard practice.

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