Two lessons and an argument for data from recent HDC complaint

9 April 2021

By Dr Peter Moodie, College clinical advisor 

No doctor wants to receive a complaint from the Health and Disability Commissioner (HDC) or worse, an adverse decision. It’s stressful for those involved but gives us all an opportunity to learn. The College has recently started putting the findings of the HDC on our website for GPs to learn from.

At times it can be disturbing to read about what has occurred but often seeing these cases helps us reflect on whether we could have been caught in the same trap(s).

I wanted to write about a recent case where acitretin was prescribed (a drug closely related to isotretinoin) along with potent topical steroids and repeated doses of oral steroids for a patient with severe psoriasis. The case highlights the following points:

Acitretin (called by the incorrect trade name of Neostigason in the report) is highly teratogenic and pregnancy must be absolutely excluded, and reliable contraception instituted, a month before commencing the drug. Contraception must be continued along with regular pregnancy tests, for three years after stopping the acitretin. In this case, the doctor relied on the patient’s word that she was on contraception and was not pregnant, only to find a month later that she was, and probably was at the time of the initial consultation.  To compound matters the patient became pregnant again eighteen months after stopping the acitretin, with both events resulting in terminations. 

The first lesson

When unfamiliar with a drug, doctors must do some research to become familiar with them and that may take half an hour but it’s time well spent. The Medsafe datasheets along with The New Zealand Formulary are ideal sources and give specific instructions on the protocols to be followed with this drug.  

The second lesson 

Patients often don’t take in all that is being said to them or asked of them; in this case pregnancy tests would have avoided these disasters.

The case was further complicated by the patient being on regular topical clobetasol (Dermovate/Dermol), which she was overusing, although this was not obvious to the doctor or some other members of the practice who were repeating scripts for her without necessarily checking the case notes.  Notwithstanding, one of the practice doctors realised this and sent the patient a letter warning her about her overuse and placed a warning in her notes. However, this was swamped by several minor non-clinical alerts and so wasn’t easily seen.  Furthermore, two letters from dermatologists advising the cessation of clobetasol were not acted on. Finally, a locum increased the number of tubes of clobetasol from two per script to six with repeats; again, not noted by the other doctors.  This, and the frequent prescribing of oral steroids, resulted in the patient developing Cushing’s syndrome and instigated the HDC complaint. 

The warning bells were all there 

The warning bells were all there, but the fact that the repeat scripts were printed out by the practice nurses and then signed without the case notes necessarily being available compounded the errors. These issues have now been improved by moving to e-prescribing where the doctor generates the script from the PMS system. However, it is likely that the previous system is common in several practices.

Finally, the Commissioner was critical of the ‘the practice’ itself, which tried to absolve itself of clinical responsibility and stated that it was the individual practitioners who were responsible. A practice is there to ensure that its systems and clinical processes work efficiently and safely and cannot abrogate that responsibility.

Several small errors by clinicians who thought they were doing a good job resulted in damage to a patient and heartache for the doctor and we can all learn from that.    

Lessons learnt

  • When unfamiliar with a drug, doctors need to spend time to research it
  • Medsafe data sheets and the New Zealand Formulary are excellent resources
  • Data – like a pregnancy test – should always be favoured over patients’ recalling information
  • It’s easy to miss important notes and alerts amongst many alerts on a patient’s file – try and take care to review them all
  • There needs to be careful recording of advice given by external sources in consultation letters.