“You’ve probably heard of the Swiss cheese model of errors… this case had more holes than it had actual cheese.” LOL. I’m going to have to adopt this turn of phrase, as it applies only too often in our current medical system.
Ignoring the ridiculous idea of discharging MRSA septic joint on a 1st gen cephalosporin…why start linezolid, see improvement, and then switch to vanco right before discharge?
I assume it had something to do with what was covered, but it seems like this could have been handled with vanc from the get go.
DILI can cause kidney injury (kidney gets overwhelmed by prolonged liver toxicity). This goes back to the first hospitalization and that inappropriate and prolonged cefazolin use. Sometimes lawsuits focus myopically on timing rather than root cause. The 2nd hospitalization was consequent to the first one, yet only the 2nd got blamed.
Curious where the pharmacist got the idea that an inpatient admission could be extended solely to follow up on a vancomycin dose adjustment and repeat level, or that a pharmacist could make that happen (I’m an inpatient pharmacist and would never have had that kind of pull!) It’s more plausible to expect them to call the discharging physician to have the home dose held/reduced.
Given the dates, I suspect the reason they had to switch from linezolid to vanc was cost, which makes this outcome even sadder.
Yeah I can't imagine a pharmacist calling and demanding that a discharge be cancelled. I'm not sure how things look from your side, but I'm guessing the pharmacist might change the dosing as needed and never even realize the patient got discharged after that. Not really your job to go back the next day and check what happened with each of the patients you previously adjusted doses on.
Had the same thoughts re: linezolid vs. vanc costs.
You would have to get pretty lucky to be able to see any lab orders or results after the patient was discharged. It’s hard now, and it certainly wasn’t any easier in 2015. (And as a pharmacist attending length of stay huddles in 2015… I was mostly there to get scolded about IV meds delaying discharge, whether I could help or not!)
We did follow up daily on vanc patients - watching micro, kidney function, and when levels might be due - but once they were discharged, they were gone from our patient list.
One of the things I do when reviewing cases is look at the dates. The patient was discharged on a Thursday before the long holiday weekend (Labor Day). Her next lab didn't result until 8 September, which was the first available business day after Labor Day weekend. There would have been impetus to discharge patients in anticipation of reduced staffing plus a delay in any follow-on care because of the holiday.
The most outrageous part was discharging on cefazolin for this. It's fine if they had to change to vancomycin, but they should have kept her for another level. The whole hospital seems incompetent with their protocols. Our pharmacists would be calling non stop if I was trying to dc on cefazolin for mrsa, and they would also call me regarding the vanc level.
“You’ve probably heard of the Swiss cheese model of errors… this case had more holes than it had actual cheese.” LOL. I’m going to have to adopt this turn of phrase, as it applies only too often in our current medical system.
Ignoring the ridiculous idea of discharging MRSA septic joint on a 1st gen cephalosporin…why start linezolid, see improvement, and then switch to vanco right before discharge?
I assume it had something to do with what was covered, but it seems like this could have been handled with vanc from the get go.
DILI can cause kidney injury (kidney gets overwhelmed by prolonged liver toxicity). This goes back to the first hospitalization and that inappropriate and prolonged cefazolin use. Sometimes lawsuits focus myopically on timing rather than root cause. The 2nd hospitalization was consequent to the first one, yet only the 2nd got blamed.
Curious where the pharmacist got the idea that an inpatient admission could be extended solely to follow up on a vancomycin dose adjustment and repeat level, or that a pharmacist could make that happen (I’m an inpatient pharmacist and would never have had that kind of pull!) It’s more plausible to expect them to call the discharging physician to have the home dose held/reduced.
Given the dates, I suspect the reason they had to switch from linezolid to vanc was cost, which makes this outcome even sadder.
Yeah I can't imagine a pharmacist calling and demanding that a discharge be cancelled. I'm not sure how things look from your side, but I'm guessing the pharmacist might change the dosing as needed and never even realize the patient got discharged after that. Not really your job to go back the next day and check what happened with each of the patients you previously adjusted doses on.
Had the same thoughts re: linezolid vs. vanc costs.
You would have to get pretty lucky to be able to see any lab orders or results after the patient was discharged. It’s hard now, and it certainly wasn’t any easier in 2015. (And as a pharmacist attending length of stay huddles in 2015… I was mostly there to get scolded about IV meds delaying discharge, whether I could help or not!)
We did follow up daily on vanc patients - watching micro, kidney function, and when levels might be due - but once they were discharged, they were gone from our patient list.
Thanks so much for discussing the possible reason for switching from linezolid to vancomycin. I was completely mystified. https://pmc.ncbi.nlm.nih.gov/articles/PMC3597396/
One of the things I do when reviewing cases is look at the dates. The patient was discharged on a Thursday before the long holiday weekend (Labor Day). Her next lab didn't result until 8 September, which was the first available business day after Labor Day weekend. There would have been impetus to discharge patients in anticipation of reduced staffing plus a delay in any follow-on care because of the holiday.
The most outrageous part was discharging on cefazolin for this. It's fine if they had to change to vancomycin, but they should have kept her for another level. The whole hospital seems incompetent with their protocols. Our pharmacists would be calling non stop if I was trying to dc on cefazolin for mrsa, and they would also call me regarding the vanc level.