Skowhegan practitioners fined over medication error cited in patient’s death

Posted Feb. 19, 2013, at 3:41 p.m.
Last modified Feb. 19, 2013, at 6:28 p.m.

SKOWHEGAN, Maine — A doctor and physician assistant practicing in Skowhegan have been reprimanded and fined by a state licensing board after the death of a patient.

Dr. Florello Quianzon and physician assistant Kathleen Lees were reprimanded by the Maine Board of Licensure in Medicine and each fined $1,000 for a medication error in February 2012 that preceded the patient’s death, according to news releases from the board.

The patient received incorrect medication at a dosage that was five times the appropriate level, according to Lees’ Feb. 12, 2013, consent agreement. The medication additionally posed a danger because of potential adverse interaction with other drugs the patient already was taking.

Quianzon missed the error because he failed to reconcile the patient’s medication when he signed the hospital discharge summary, according to his Feb. 12, 2013, consent agreement. The discharge summary was prepared by Lees, who, as “mid-level provider” at the hospital, cannot discharge patients without a review by a physician, Quianzon’s agreement states.

Quianzon attributed the mistake to a dictation error, saying he, Lees and a discharge nurse all missed the medication inaccuracy.

The consent agreements do not name the patient or the hospital. Quianzon and Lees are employed by Redington-Fairview General Hospital, according to licensing records and the hospital’s website.

According to a Feb. 24, 2012, “statement of deficiency” supplied by DHHS, Redington-Fairview medical staff also failed to recognize symptoms of a potential drug overdose when the patient returned to the hospital.

The 59-year-old patient first was admitted to the hospital after visiting the emergency department on Feb. 2, 2012, complaining of a fever, the document states. The patient was a resident of Woodlawn Nursing and Rehabilitation Center in Skowhegan.

When the patient was discharged on Feb. 7, 2012, the medical summary erroneously omitted an anticonvulsant medication the patient had been taking in the nursing home and at the hospital under a list of “unchanged” medications. The list wrongly included a different anticonvulsant drug at an excessive dosage, the document states.

The patient returned to the hospital’s emergency room the next day and was “nonverbal” and complaining of “decreased mental status.” The patient’s lab results were abnormal, including high blood sugar, according to the statement of deficiency.

The physician and nurse who treated the patient that day later told investigators they did not notice the new medication or unusually high dose in the patient’s records.

The patient was discharged later that day in “stable condition” with no recorded diagnosis. After returning to the nursing home, the patient received four doses of the wrong medication over the next week, based on the faulty hospital paperwork. The patient died on Feb. 16, 2012, according to the statement from DHHS.

The patient’s primary care physician stated to investigators that the medication error contributed to the patient’s death, the document states.

The hospital failed to recognize the medication error for more than a week — from Feb. 7, 2012, to Feb. 17, 2012 — and took no corrective action for another six days after that, according to the DHHS statement.

In a prepared statement, Redington-Fairview medical director Dr. Michael Lambke said the hospital fully supports Quianzon and Lees as “highly qualified practitioners” and appreciates their cooperation in “this sad incident.”

“A thorough investigation and critique of all systems related to this incident has been completed,” he said. “Corrective prophylactic safeguards have been instituted, re-evaluated and fine-tuned.”

The medical licensing board learned of the patient’s death in September 2012 through an investigation conducted by the Maine Department of Health and Human Services Division of Licensing and Regulatory Services.

A spokeswoman for Redington-Fairview said DHHS imposed no sanctions against the hospital as a result of the incident.

The reprimands do not limit Quianzon and Lees in practicing medicine, but will remain permanently on their professional records.

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