Medical Malpractice Insights: The “5 R’s” of Medications

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Chuck Pilcher, MD, FACEP

Editor, Medical Malpractice Insights

Editor, Med Mal Insights

The “5 R’s” of medications 

Case 1: Teen dies from overdose.


Facts: A 15-year-old uncooperative autistic boy requires general anesthesia for multiple dental procedures. He is admitted as an outpatient, and the necessary work is done by his oral surgeon and a resident. On discharge he is given a prescription for acetaminophen with codeine, but his mother tells the resident that her son absolutely will not take any oral medication. The resident discusses options with the mother, consults his attending, and they elect to apply a fentanyl patch for his post-op pain. The resident consults the EMR and chooses the 100mcg/hr patch from the drop-down menu of dosages. The patch is brought from the hospital pharmacy and given to the mother to apply it if her son has significant pain. She applies it to the teen’s upper back at bedtime, and he is found dead the next morning. His fentanyl level at autopsy is 19.1 ng/ml (therapeutic level 1-3 ng/ml). A claim is filed against the hospital, oral surgeon, and resident.

Plaintiff: You prescribed a Duragesic patch without having a clue what the appropriate strength was for a patient my son’s age and size. You clicked a box on an EMR without any knowledge of this drug. The drug even carries a “black box warning” for prescribers. You violated nearly all of the listed warnings, especially the one that warns against prescribing Duragesic to an opioid-naive patient like my son. Even if a patch was appropriate, you prescribed one 8 times stronger than appropriate. Neither the discharge nurse nor the pharmacist intervened when they had an opportunity to do so. My son stopped breathing and died because of your incompetence. This was totally preventable.

Defense: There’s not much we can say. The record speaks for itself. Let’s discuss a confidential settlement and avoid getting this into the public record.

Result: Settlement for an undisclosed amount.

Takeaways:. This tragic error could have been prevented with several safeguards in place:

  • Double check the “5 R’s”: Right drug, patient, dosage, route, and time. One could argue that every “R” was missed except the “Right patient.”
  • Be familiar with the drugs, dosages, and forms of the medications you prescribe. Use extra caution when prescribing a drug you would not normally use in the same situation, e.g., fentanyl patch vs. acetaminophen with codeine.
  • If you’re a resident, don’t assume that your attending knows what they’re talking about. Do your own homework.
  • If you’re an attending, don’t assume that your resident knows what you’re talking about. Be clear. Be specific. Know your drugs and dosages.
  • As an attending, monitor your residents and assure that they are comfortable questioning you without embarrassment or humiliation.
  • Pharmacists should recognize and question drugs and dosages that are outside the normal routine of their experience and practice.
  • A nurse providing instructions for home care or transmitting a prescription to a pharmacy might be the last line of defense. If something doesn’t look right, question it. Discussing unfamiliar drugs, forms, and dosages with the prescriber is an opportunity to learn as well as prevent error.

But wait! There’s more!

Case 2: A near miss 7 years later at the same hospital.


Facts: Seven years later, a 13-year0ld boy falls from a tree sustaining a fracture of the elbow and is seen in the ED of the same hospital as in Case 1. He is evaluated, treated, and discharged with a prescription for oxycodone. The mother takes the prescription to a pharmacist who asks “How old is the patient?” When he hears “13,” he tells the mother “We don’t have this medication.” The mother goes to a second pharmacy where the same scenario is repeated. At a third pharmacy, when the pharmacist hears her son’s age, he bluntly tells her “I’m not going to fill this prescription. The dosage is too high. If your son takes it, he could die.” The mother is horrified, hurries back to the hospital ,and confronts the prescribing physician. When shown the prescription, the physician admits to the mistake and apologizes. Because the third pharmacist was diligent and told the mother the truth, a tragic error was avoided.

Result: Since the error was caught, this “near miss” did not result in a lawsuit. The hospital assured the mother that they would modify their practices to keep this from happening again.


  • We must learn from our mistakes if we are to improve patient safety.
  • How much did this hospital learn from its first mistake? What, if anything, changed 7 years earlier?
  • The first time it’s a learning opportunity. The second time it’s a mistake.


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