Inadequate Screening of Patient with Substance Use Disorder Has Fatal Ending

Description

A middle-aged adult with a history of depression, anxiety, and alcohol use disorder died by suicide after not receiving adequate screening, referrals, or follow-up.

Clinical Sequence

A 58-year-old male patient with a medical history of high blood pressure, diabetes, and alcohol use disorder was being treated by a nurse practitioner (NP) for smoking cessation. The patient was prescribed Chantix for smoking and reported he had not smoked for over a year. The patient reported to the NP that he was drinking at least six to eight beers per night, which was increasing his blood sugar levels. At this point, the NP did not refer the patient to any substance use support services.

A few months later, the NP saw the patient for depression and anxiety, which was precipitated by fear he may lose his business. The patient had resumed smoking and reported increased, extreme anxiety. He stated he had not slept in over a week and had been taking his friend’s Alprazolam (anti-anxiety medication). The NP prescribed the patient Lorazepam for anxiety, and he was instructed not to take this medication with alcohol.

The patient returned the following month stating he was still not sleeping. The NP documented “No depression, no life stressors” in his chart. Eighteen months later, the patient reported he was highly anxious, still drinking alcohol at night, depressed over his failing business, and had lost 15 pounds. At the time, the patient was taking Chantix along with two anti-anxiety medications (Clonazepam and Lorazepam) and an anti-depressant (Citalopram), all of which were prescribed by the NP.

The patient called the NP requesting additional medication for anxiety. The NP counseled the patient to try to relax and “let the medication work.” The NP did not refer him to mental health services or assess him for suicidal ideation.

The next day, the patient was found to have died by suicide.

Allegation

The patient’s wife alleged a failure to screen for suicidal ideation and ensure safety in a patient with a history of alcohol use disorder and multiple life stressors.

Disposition

This case was settled in the medium range (approx. $500,000).

Analysis

Lack of/inadequate patient assessment

• Despite the patient reporting extreme anxiety, insomnia, weight loss, depression, and extreme life stressors, the provider never completed a thorough assessment, including an assessment for suicidal ideation.

Failure/Delay in obtaining a consult/referral

• Experts were critical of the provider for not referring the patient to Alcoholics Anonymous, a substance abuse counselor, or an alcohol detox program to receive support for alcohol use disorder.
• Given all of the patient’s ongoing issues and stressors, a referral to a therapist, psychopharmacologist, or mental health specialist was warranted

Failure to ensure patient safety

• The patient had intermittent interactions with the provider and inconsistent follow-up after being prescribed several medications, such as benzodiazepines, that carry a risk of accidental or incidental death when mixed with alcohol.
• The provider did not document any depression or suicide screenings.

Lack of patient education on medications

• The provider should have completed and documented patient education related to the potential adverse effects of the several medications the patient was taking.
• Education should also have been provided on immediate next steps to take if the patient experienced worsening psychiatric/psychological symptoms to ensure safety.

Discussion Questions

1. What documentation practices could have been improved in this case to provide a clearer record of the patient’s condition and care, and how might thorough documentation help reduce liability?
2. How can providers ensure that they properly educate patients on the risks and interactions of prescribed medications, especially when patients have co-occurring conditions like substance use disorder?
3. What are the key indicators that should prompt a provider to refer a patient to specialized care, and how might timely referrals to mental health or substance use treatment services reduce malpractice risk?
4. In what ways can providers ensure adequate follow-up and monitoring for patients who are prescribed medications with a high risk of adverse interactions, particularly in cases involving substance use?
5. What protocols can health care organizations adopt to better support nurse practitioners and other providers in managing complex cases to help reduce the risk of medical error?

Resources

• Core Resource on Alcohol | National Institute on Alcohol Abuse and Alcoholism (NIAAA)

• Practitioner Training | Substance Abuse and Mental Health Services Administration (SAMHSA)

• Suicide Prevention Resource Center