Being a grandfather or grandmother is one of life’s most rewarding experiences. While reliving the early stages of life with our grandchildren we can enjoy their movies and get a second chance at some which we may have missed. I was recently watching Mary Poppins with my grandkids and found it delightful and uplifting. For days, I was rehashing that famous song in my head, “just a spoonful of sugar helps the medicine go down.” As a clinician, I paused with some concern as I had to ask myself: What, actually, is a spoonful?
It is in the purview of physicians, NPs and PAs in pediatrics, family practice, internal medicine, urgent care, emergency medicine, retail health care and geriatrics to examine their patients who present with symptoms of a cold, allergy symptoms or a cough, resulting with a note recommending some form of OTC medicine. We commonly use the phrase “one or two teaspoons” and either document (or fail) to document this dosage. Either way, the potential for creating an iatrogenic poisoning or a drug reaction is quite high. It is always important to know what medications your patient may be taking – a critical practice which should accompany every patient encounter, whether new or not. Most PAs and NPs enter healthcare with the idea of working for 30-40 years but prudent attention to malpractice prevention can never start too early. Thorough, thoughtful practice can illuminate cross-sensitivity to prescribed OTC drugs. We need to look at OTCs as carefully as we would any prescribed medication, and it is equally important to know the age and weight of your patient, as a spoonful may be too little or too much. If the patient is a pediatric patient, the parent may be confused by the description of a spoonful and give a tablespoon, a teaspoon or a pediatric feeding spoonful. Children who are taking a drug, particularly an OTC drug, have a much greater possibility of a reaction.
For many of our senior citizens on polypharmacy, there are many potential drug-drug-interactions that will increase or decrease the effectiveness of their other medications making way for hypertension, severe hypotension or rhythm changes related to their cardiac drugs. For a moment, consider the patient on Coumadin. This drug has restrictions on other medications, as well as foods and alcohol which can greatly affect the INR and create a life- threatening bleed in the brain or in the GI system. I was scolded by my cardiologist a few years ago for taking a class III antiarrhythmic with herbal drugs or vitamins and minerals. He made me wait an additional hour in his office, then had me step into his private room and asked me, “What is it that you don’t understand about taking NO additional supplements or herbs?” As a healthcare professional, he was shocked at my actions. These substances can interact with my prescribed drug regimen to the degree that I could have developed Torsade’s De Pontes. He asked me if my need to take supplements – including fish oil, glucosamine and chondroitin – surpassed my need to live. His direct approach about my nonchalant attitude regarding supplements certainly got my attention!
Being careless can lead to a poor outcome for the patient, as well as a possible lawsuit. What can the collective “we” do to prevent a patient incident that is negative or life threatening? Check for other medications, review current drugs, look at age and weight and be cautious to write an OTC medication unless aware of all of the possible reactions. Is there anything else to glean from this? Another related concern is failure to document the other medications and to cross reference all contraindications, which are frequent causes for litigation involving PAs as well as NPs and particularly in the setting of the Retail Healthcare Clinic or Urgent Care Center. The same focus should apply to Telemedicine since it has become particularly popular during the pandemic. These concerns should encourage clinicians to consider how to best protect themselves, their professional futures and their families from litigation due to negligence.
Accuracy is the name of the game and is the mandate for all healthcare professionals but owning proper professional liability is the safest solution for potential error. Quality PA Professional Insurance is important to understand, easy to get, and provides the stable and individualized protection your career demands. It is not a coincidence that you are reading this today, but a heartfelt concern of a colleague who wishes all PAs and NPs a long and successful career. You do not want to create a life-threatening situation or worse. Our ultimate goal is to retire with professional pride and satisfaction – with NO history of careless nonchalance or, pardon the expression, “sloppiness”. Perhaps this “spoonful” of advice might help.
By Robert M. Blumm, PA, DFAAPA, PA-C Emeritus
PA Advisor to CM&F