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Management of medication for patient with complex health issues (15HDC00196)
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(15HDC00196, 23 June
General practitioner ~ Medication toxicity ~ Lithium serum ~
monitoring ~ Right 4(1)
A 49-year-old man complained about the care provided by his
general practitioner (GP). The man had complex and longstanding
psychiatric issues and a number of physical co-morbidities,
including diabetes, obesity, obstructive sleep apnoea, fatty liver
and previous pulmonary embolus. When the man became a patient of
the GP he was on a drug regimen that included high doses of
diazepam, paroxetine, lithium and codeine. This drug regimen had
been established by psychiatrists in both New Zealand and
Over a period of six years, the man was prescribed lithium
without regular reviews of his serum lithium levels. Serum lithium
levels are taken to ensure that patients on lithium are not
developing lithium toxicity.
In February 2011 blood tests indicated deterioration in the
man's renal function (his test results were outside the normal
range). In November 2011 the man reported a hand tremor, a common
side effect of lithium toxicity.
In November 2011 the man was reviewed by a consultant
psychiatrist who recommended changes to the man's paroxetine
prescription. These changes were not implemented at the practice
until September 2012.
Additionally, in January 2012, the GP's practice received notice
from a DHB endocrinology service that the lithium levels should be
reduced. Recommended changes to the man's lithium prescriptions
were not implemented until September 2012.
The GP failed to assess the serum lithium levels adequately, did
not document any consideration that the man might be suffering side
effects from lithium toxicity, took no action to assess whether the
lithium might be causing the tremor or the deterioration in renal
function, and failed to ensure that specialist ordered changes to
the man's medication regimen were made in a timely manner. While it
was acknowledged that the patient's conditions and management were
complex and a mitigating factor when considering those failures, it
was found that the GP did not provide services to the man with
reasonable care and skill, and breached Right 4(1).
The GP's practice failed to have systems in place to facilitate
co-operation between providers to ensure that quality and
continuity of services were provided to the man and, accordingly,
breached Right 4(5).
The Commissioner recommended that the GP provide a written
apology to the man and undertake training on the prescribing of
It was recommended that the Medical Council of New Zealand
consider whether a review of the GP's competence was warranted.
It was recommended, with specific reference to Royal New Zealand
College of General Practitioners Foundations Standards, that the
GP's practice develop and finalise a repeat prescribing policy that
includes information on patient review timeframes; and a policy for
the robust filing of reviews and reports, including specialist
advice, received by the practice that require action.