Third Skowhegan practitioner fined over medication error cited in patient’s death

By Jackie Farwell, BDN Staff
Posted April 16, 2013, at 12:30 p.m.

SKOWHEGAN, Maine — A Skowhegan doctor has been reprimanded and fined by a state licensing board for failing to spot a medication error that preceded a patient’s death.

Deep Acharya accepted a reprimand and $1,000 fine from the Maine Board of Licensure in Medicine, according to a Tuesday press release from the board. Acharya failed to identify an incorrect medication that previously had been prescribed when the patient was brought to a hospital emergency department in February 2012, according to Acharya’s April 9 consent agreement with the board.

The consent agreement does not name the patient or the hospital. Acharya practiced at Redington-Fairview General Hospital in Skowhegan, according to a state medical licensing database.

Two other Redington-Fairview employees, Dr. Florello Quianzon and physician assistant Kathleen Lees, were reprimanded and fined by the medical licensing board in February as a result of the medication error.

The patient received incorrect medication at a dosage that was five times the appropriate level. 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 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 stated.

The 59-year-old patient was a resident of Woodlawn Nursing and Rehabilitation Center in Skowhegan, according to a “statement of deficiency” that further details the circumstances surrounding the patient’s death. The statement of deficiency was supplied to the Bangor Daily News in February by the Maine Department of Health and Human Services.

When the patient was discharged from the hospital 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 a day after being discharged and was seen by Acharya, according to the board’s press release. The patient was “nonverbal” and complaining of “decreased mental status” and her lab results were abnormal, including high blood sugar, according to the statement of deficiency.

Redington-Fairview medical staff failed to recognize symptoms of a potential drug overdose, the document states. Acharya told the board that he presumed the medication was specifically planned for the patient and did not cause him alarm. After running some tests, Acharya discharged the patient with instructions to return if her symptoms worsened.

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 of deficiency. The patient’s primary care physician stated to investigators that the medication error contributed to her death.

Looking back, Acharya said he would have paid closer attention to the medication reconciliation process, which would have helped him identify the abnormal drug dosing, the press release states.

The reprimand does not limit Acharya, who was licensed in Maine in September 2011, in practicing medicine. It will remain permanently on his professional record.

http://bangordailynews.com/2013/04/16/health/third-skowhegan-practitioner-fined-over-medication-error-cited-in-patients-death/ printed on October 1, 2014